Q     OOP  005  650 


v 


THE  LIBRARY 
OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


r 


A    SYSTEM 


OP 


OEAL  SUEGEEY: 


BEING 


A    CONSIDERATION    OF    THE 


DISEASES  AND  SURGERY 


OP    THE 

MOUTH,  JAWS,  AND  ASSOCIATE  PARTS. 


BY 

JAMES   E.  GARRETSON,  M.D.,  D.D.S., 

Oral  Surgeon  to  the  Medical  Department  of  the  University  of  Pennsylvania;  Author  of  Diseases 

and  Surgery  of  the  Mouth,  Jaws,  and  Associate  Parts ;  late  Lecturer  on  Anatomy  and 

Surgery  in  the  Philadelphia  School  of  Anatomy  ;  late  Professor  of  the  Principles 

and  Practice  of  General  Surgery  in  the   Philadelphia  Dental  College; 

Member  of  the  Philadelphia  Pathological  Society ;   Member  of 

the  Odontographic  Society  of  Pennsylvania  ;  Member  of 

the  Delaware  County  Medical  Society,  etc. 


IUu;5itvHtfd  mill  |tumevo«,g  ^Usl  glnit^  mt\  n^ooA-mt^, 


PHILADELPHIA: 

J.   B.    LIPPINCOTT    &    CO. 

18  7  3. 


Entered  according  to  Act  of  Congress,  in  the  year  1872,  hy 

J.  B.  LIPPINCOTT   &   CO., 
In  the  Office  of  the  Librarian  of  Congress  at  "Washington. 


Lippincott's  Press, 
Philadelphia. 


^^^^ 


.4J 


TO      THE 

LEARNED   AND   DISTINGUISHED  GENTLEMEN 

CONSTITUTING  THE   CORPS, 
PROFESSORIAL     AND     CLINICAL. 

OP    THE 

UNIVERSITY   OF   PENNSYLVANIA, 

WITH    WHOM     IT    IS    THE    PLEASURE    AND    PRIVILEGE    OF    THE    AUTHOR    TO    BE 

ASSOCIATED, 


PREFACE 

TO    THE    SECOND    EDITION. 


The  kind  reception  accorded  to  the  volume  of  which 
the  present  one — though  greatly  modified  and  enlarged, 
and  under  a  different  title — may  be  considered  a  second 
edition,  has  aroused  the  warm  gratitude  of  the  author, 
and  stimulated  him  to  exertions  which  he  trusts  will  be 
found  to  have  rendered  the  present  effort  more  worthy  of 
the  commendations  so  generously  bestowed  upon  his  labors. 

Since  the  issue  of  the  previous  work — a  period  of  rather 
more  than  two  years  having  elapsed — the  author  has  de- 
voted himself  somewhat  exclusively  to  investigation  and 
observation  in  the  •  direction  of  the  specialty  herein  dis- 
cussed. Favored  happily  with  opportunities  not  commonly 
enjoyed  both  in  the  direction  of  hospital  and  of  private 
practice,  he  may  not  but  feel  satistied  of  the  value  and 
solidity  of  the  experiences  and  teachings  here  recorded. 

The  present  volume  has  been  entitled  a  system:  a 
system  the  author  has  exerted  himself  to  make  it ;  step 
by  step,  from  the  elements  of  the  subject — from  the  first 
departures  from  normal  life — attempt  has  been  made  to 
follow  the  various  conditions  to  and  through  their  pro- 
foundest  complications. 

During  the  time  of  writing  the  book,  the  author  has 
had  continuously  in  mind  the  recognition  of  the  important 
fact  that  in  no  department  of  medical  science  has  there 
existed  a  hiatus  such  as  that  found  to-day  between  general 
surgery  and  dentistry, — a  lacking  span,  trul}^,  in  the  bridge  of 
practice.  A  patient  with  an  oral  disease  of  any  complexity, 
trusting  himself  to  the  average  dentist,  meets  wnth  disaster 
because  of  the  absence  of  surgical  knowledge  and  skill. 
Approaching  from  the  side  of  medicine,  he  suffers  alike  from 

(V) 


vi  PEEFACE   TO    THE  SECOND   EDITION. 

the  want  here  of  a  special  character  of  information  which 
has  hitherto  been  looked  upon  as  having  relation  alone  with 
a  specialty. 

To  bridge  this  gap  by  supplying  the  lacking  span  is  the 
highest  ambition,  as  it  has  been  the  almost  life-long  labor, 
of  the  author.  Any  sacrifice  that  may  have  been  made 
in  the  work,  and  in  the  preparation  of  the  present  volume, 
will  find  ample  compensation,  if  the  dental  practitioner 
learn  from  it  that  an  acquaintance  with  the  principles  of 
medicine  is  necessary  to  the  comprehension  of  oral  surgery ; 
and,  on  the  other  hand,  if  the  general  practitioner  be  led  to 
perceive  the  necessity  for  a  familiarity  with  that  which  hith- 
erto has  been  deemed  to  belong  exclusively  to  the  province 
of  the  dentist :  that  both  may  realize  that  oral  surgery  is  a 
specialty  to  which  no  man  may  bring  learning  and  skill 
which  shall  not  find  abundant  opportunity  for  their  highest 
expression. 

How  oral  surgery  shall  be  practiced,  whether  by  the 
general  surgeon,  or,  as  in  ophthalmic  surgery,  by  a  special- 
ist, the  author  is  not  concerned  to  discuss:  what  is  for  the 
highest  good  comes  through  a  law  of  its  own  to  grow 
into  usage.  What  is  to  be  the  manner  of  the  medical 
practice  of  the  future  may  safely  be  left  to  that  future. 

To  his  publishers,  for  a  liberality  which,  as  the  volume 
will  show,  involved  a  large  latitude  in  expense;  to  S.  S. 
"White,  Esq.,  for  the  unstinted  use  of  his  valuable  collection 
of  cuts,  and  for  numberless  favors, — the  conferring  of  which 
must  have  cost  much  trouble ;  to  Dr.  Butler,  publisher  of 
the  "Medical  and  Surgical  Reporter,"  for  cuts,  and  also 
to  Messrs.  Johnson  &  Lund  and  to  Mr.  Kolbe,  for  similar 
favors,  the  author  returns  his  sincere  thanks. 

To  his  friends  and  clinical  assistants,  Drs.  De  Forrest 
Willard  and  Elliott  Richardson,  for  aid  in  preparing  the 
index,  and  to  Dr.  Vallette,  for  drawings  made  of  clinical 
cases,  he  desires  to  express  his  obligations. 

Philadelphia,  1537  Chestnut  Street, 
:Nov.  1,  1872. 


PREFACE 

TO    THE    FIRST    EDITION. 


In  the  fulfillment  of  many  promises  made  from  time 
to  time  to  bis  students  and  other  friends,  the  author  has 
prepared  the  following  pages,  as  embodying  the  results  of 
his  observations  and  experiences  during  a  somewhat  ex- 
tended practice  in  that  branch  of  the  profession  to  which  it 
specially  relates. 

"With  the  hope  that  the  volume  will  be  a  useful  text-book 
in  assisting  the  student  to  prepare  for  the  responsible  duties 
of  the  profession,  and  a  reliable  guide  to  the  intelligent 
practitioner,  it  is  herewith  oftered  to  the  attention  both  of 
those  who  are  about  to  enter  the  field  of  their  labors  and  of 
those  who,  though  more  familiar  with  the  practical  duties 
thereof,  may  desire  to  acquaint  themselves  more  fully  with 
the  latest  methods  of  practice. 

That  the  work  may  prove  a  source  of  benefit  to  his  fellow- 
beings  is  the  highest  hope  concerning  it  of 

The  Author.  . 


CONTENTS. 


CHAPTEK  I. 

PAGE 

Surgical  Anatomy  of  the  Mouth  and  Face 29 

CHAPTER  II. 
Tlie  Mouth 57 

CHAPTER  III. 
The  Fifth  Pair  of  Nerves 77 

CHAPTER   IV. 
Dentition 93 

CHAPTER  Y. 
Dentition — Continued 101 

CHAPTER  VI. 
Associative  Lesions  of  First  Dentition Ill 

CHAPTER  VII. 

Anomalies  of  Second  Dentition  and  their  Surgical  Relations 141 

CHAPTER  VIII. 
The  Teeth  and  their  Diseases — Alveolar  Abscess 170 

CHAPTER  IX. 
Anchylosis  of  the  Jaw 182 

CHAPTER  X. 
Dental  Caries 214 

CHAPTER  XI. 

The  Local  Treatment  of  Dental  Caries 274 

(ix) 


X  CONTENTS. 

CHAPTER  XII. 

PAQE 

Filling  Teeth 281 

CHAPTER  XIII. 
Pilling  Teeth— Continued 307 

CHAPTER  XIV. 
Odontalgia 361 

CHAPTER  XV. 
Pilling  the  Pulp  Chamber  and  Canals 384 

CHAPTER  XVI. 
The  Extraction  of  Teeth 395 

CHAPTER  XVII. 

General  Remarks  on  Extraction  of  Teeth,  Local  Ana3Sthesia,  etc 422 

CHAPTER  XVIII. 
General  Anjesthesia — Ether 431 

CHAPTER  XIX. 

General  Anaesthesia — Chloroform 441 

CHAPTER  XX. 

Artificial  Dentures — Pivot  and  Plate  Teeth 456 

CHAPTER  XXI. 
Irregularities  of  the  Teeth 478 

CHAPTER  XXII. 
Salivary  Calculus 495 

CHAPTER   XXIII. 
Denudation  of  Dentine 505 

CHAPTER  XXIV. 
Salivary  Fistulse 507 

CHAPTER  XXV. 
The  Tonsil  Glands 516 


CONTENTS.  xi 


CHAPTER  XXVI. 

PAGE 

The  Gums  and  their  Diseases 532 

CHAPTER  XXVII. 
Caries  of  the  Maxillje 5o2 

CHAPTER  XXVIII. 
Necrosis  of  Maxillte 56G 

CHAPTER  XXIX. 
Wounds  of  the  ilouth  and  Associate  Parts 598 

CHAPTER  XXX. 
Fractures  of  the  31axillary  Bones 623 

CHAPTER  XXXI. 

Dislocation  of  the  Inferior  Maxilla 637 

CHAPTER  XXXII. 
Ozaena 644 

CHAPTER  XXXIII. 
The  Antrum  of  Highmore,  and  its  Diseases 658 

CHAPTER  XXXIV. 
TheAphthaj 674 

CHAPTER  XXXV. 
Ranula 695 

CHAPTER  XXXVI. 
Neuralgia 709 

CHAPTER  XXXVII. 
The  Tongue  and  its  Diseases 756 

CHAPTER  XXXVIII. 
Tumors,  General  Consideration  of 804 

CHAPTER  XXXIX. 
Tumors  of  the  Mouth— the  Epulides 819 


Xll 


CONTENTS. 


CHAPTEK  XL. 

PAGE 

Tumors  of  the  Mouth— Exostosis 833 

/ 

CHAPTEK  XLI. 

Tumors  of  the  Mouth— Cystic  Tumors 84G 

CHAPTEPv  XLII. 

Tumors  of  the  Mouth — Non-explainable  Tumors .' 874 

CHAPTER  XLIII. 

Tumors  of  the  Mouth— Non-explainable  Tumors 895 

CHAPTER  XLIY. 
Epithelioma 918 

CHAPTER  XLY. 

Tumors  of  Parts  associated  with  the  Moutli 932 

CHAPTER  XLVI. 
Operations  upon  the  Lips  and  Cheek •. 952 

CHAPTER  XLYII. 
Operations  upon  the  Li})S  and  Cheek 973 

CHAPTER  XLVIII. 
Rhinoplastic  and  Rhino-cheiloplastic  Operations 999 

CHAPTER  XLIX. 
Palatine  Defects  and  their  Treatment 1009 

CHAPTER  L. 
Obturators 1030 

CHAPTER  LI. 
Resections'of  the  Maxillary  Bones 1058 


LIST  OF  ILLUSTRATIONS. 


Fia.  PAGE 

1.  Front  and  lateral  region  of  tlie  skull 30 

2.  Superior  maxillary  bone  of  the  left  side — outer  view 33 

3.  Superior  maxillary  bone  of  the  left  side — inner  view 33 

4.  Inferior  maxillary  bone 38 

5.  Palate  bone  of  right  side — posterior  view 41 

6.  Palate  bone  of  right  side — exterior  view 41 

7.  The  vomer — view  of  left  side 43 

8.  Articular  relations  of  vomer 44 

9.  Position  and  relations  of  turbinated  bones 45 

J,0.  Ethmoid  bone — general  view 46 

11.  The  sphenoid  bone — upper  view 48 

12.  The  sphenoid  bone — front  view 49 

13.  Anterior  view  of  the  nasal  bone 52 

14.  The  malar  bone — outer  view 53 

15.  The  lachrymal  bone — external  view 54 

16.  The  hyoid  bone 55 

17.  Antero-posterior  section  of  cranium 55 

18.  Ptight  half  of  the  base  of  the  skull 56 

19.  Muscles  of  the  face - 59 

20.  Arteries  of  the  face 60 

21.  The  common  carotid,  with  its  divisions 61 

22.  Nerves  of  the  face 63 

23.  Veins  of  the  face 64 

24.  Sectional  view  of  the  nose,  mouth,  and  pharynx 66 

25.  Side  view  of  the  muscles  of  the  tongue 67 

26.  Upper  surface  of  the  tongue 68 

27.  Papillaj  of  the  tongue — moderately  magnified 70 

28.  Diagram  of  papillse — highly  magnified 70 

29.  Vertical  section  of  the  articulation  of  the  lower  jaw 75 

30.  External  view  of  the  temporo-maxillary  articulation 75 

31.  General  view  of  the  relations  of  the  fifth  pair  of  nerves 77 

32.  Trifacial  division  and  ganglia 78 

33.  Superior  maxillary  nerve 82 

34.  Inferior  maxillary  nerve 84 

35.  Ophthalmic  ganglion — the  outer  part  of  the  right  orbit  removed 87 

36.  View  of  the  spheno-palatine  ganglion,  the  outer  wall  of  the  left  nasal 

cavity,  and  the  olfactory  nerve 88 

37.  Deciduous  teeth 93 

38.  Permanent  teeth  of  superior  jaw 94 

(  xiii ) 


xiv  LIST  OF  ILLUSTBATIONS. 

FIG.  PAGE 

39.  Permanent  teeth  of  inferior  jaw.. 94 

40.  Lateral  view  of  the  upper  and  lower  permanent  teeth 95 

41.  Vertical  section  of  a  molar  tooth 96 

42.  Transverse  section  of  a  molar  tooth 96 

43.  Vertical  section  of  a  cuspid  tooth 97 

44.  Dental  pulp — magnified 98 

45.  Nerves  of  dental  pulp 98 

46.  Tubuli  of  dentine  and  enamel 98 

47.  Vertical  section  of  the  fang  of  a  canine  tooth 98 

48.  Three  enamel  columns — highly  magnified 99 

49.  Section  of  enamel — highly  magnified 99 

50.  Interglobular  spaces  in  dentine 99 

51.  Diagram  of  the  mode  of  development  of  the  teeth 107 

52.  First  and  second  dentitions 109 

53.  Ringed  tooth 153 

54.  Metal  cap  used  in  periodontitis 155 

55.  Sac  of  alveolar  abscess 170 

56.  Kolbe's  wedge  screw 207 

57.  Wedge  of  Scultetus 208 

58.  Modified  oral  wedge 208 

59.  Superior  dental  arch — perfect  type  of 251 

60.  Superior  dental  arch — faulty  type 251 

61.  Structural  consolidation  of  dentine 275 

62.  Hoe  excavators  and  modifications  of 287,  288 

63.  Hatchet  excavators  and  modifications  of 288 

64.  Rose  and  spear  drill 288,  289 

65.  Merry's  drill 290 

66.  Bur  thimble 290 

67.  Forms  of  chisels  used  in  dentistry 291 

68.  Jack's  double-end  enamel  chisels 292 

69.  Forbes's  gouge,  and  Jack's  paraboloid  chisels 293 

70.  Separating  file— Taft's  pattern 294 

71.  File-carrier 294 

72.  Simple  cavities  on  grinding  face  of  molar  teeth 294 

73.  Cavities  on  posterior  face  of  incisors 295 

74.  Neck  cavities  in  incisor  teeth 295 

75.  Cavities  of  imperfect  enamel 295 

76.  Cavities  on  buccal  face  of  molar  teeth 295 

77.  Buccal  cavities 296 

78.  Carious  denture .' 297 

79.  Separating  files 297 

80.  Complicated  dental  cavities 298 

81.  Complicated  dental  cavities 299 

82.  Complicated  dental  cavities 300 

83.  Complicated  dental  cavities 300 

84.  Excavators,  lathe  matrices,  and  bur  drills 301 

85.  Forms  of  files  used  in  separating  molar  teeth 303 

86.  Mouth  mirror ' 306 

87.  Mouth  mirror 306 


LIST  OF  ILLUSTRATIONS.  xv 

FIG.  PAGE 

88.  Syrinsre 306 

89.  Syringe 306 

90.  Plain-pointed  plugging  instruments 307 

91.  Serrated-pointed  plugging  instruments a 307 

92.  Flagg's  tongue-holder 309 

93.  Morrison's  duct-compressor 309 

94.  Dibble's  saliva-pump 310 

95.  McQuillen's  extension-finger 311 

96.  Taft's  thimble 311 

97.  Kich's  Stenonian-duct-compressor 312 

98.  Hodson's  rubber-dam  appliances 315 

99.  Forbes's  fork  for  fixing  rubber  dam 320 

100.  Hot-air  syringe 321 

101.  Foil-carrier 323 

102.  Kedman's  pluggers 324 

108.  White's  head-rest  326 

104.  Jack's  matrix 330 

105.  Jack's  matrix 331 

106.  Fixing  points  for  Jack's  matrix 331 

107.  Jack's  matrix 332 

108.  Jack's  plugger-point 334 

109.  Outline  contour  cavities 335 

110.  Atkinson's  pluggers 338 

111.  Atkinson's  burnishers 339 

112.  Butler's  pluggers 339 

113.  Varney's  pluggers 340 

114.  Abbott's  pluggers '. 341 

115.  Plugging  mallets 343 

116.  Automatic  plugger 347 

117.  Electro-magnetic  mallet 348 

118.  Finishing  files 351 

119.  Bur  and  wheel  files 352 

120.  Set  of  burnishers 352 

121.  Porte  polishers 358 

122.  Filed  teeth 357 

123.  Diminished  pulp-chamber 377 

124.  Diminished  pulp-chamber 377 

125.  Secondary  deposit  of  dentine 378 

126.  Pulp  nodule 379 

127.  Pulp  nodule 379 

128.  Nerve  extractor,  with  holder 385 

129.  Nerve  extractors 385 

130.  Nerve-canal  pluggers 387 

131.  Permanent  teeth  of  upper  jaw 896 

132.  Permanent  teeth  of  lower  jaw.' 396 

133.  Upper  incisor  forceps 397 

134.  Lateral  incisor  forceps — upper 398 

135.  Lower  incisor  forceps — hawk-bill 398 

136.  Lower  incisor  and  bicuspid  forceps,  for  either  side 398 


xvi  LIST  OF  ILLUSTRATIONS. 

FIG.  P-^^E 

137.   Hawk-bill  forceps  for  lower  incisor  and  crowded  teeth 398 

188.  Upper  and  lower  root  forceps— half  curved 400 

139.  Lower  root  forceps — full  curved 400 

140.  Upper  and  lower  bicuspid  forceps 400 

141.  Upper  back  root  forceps — universal 400 

142.  Half  curved,  narrow  beak  forceps 400 

143.  Upper  bicuspid  and  canine  forceps 401 

144.  Upper  bicuspid  and  incisor  forceps 402 

145.  Lower  Taicuspid  and  canine  forceps 402 

146.  Lower  bicuspid  forceps 403 

147.  Upper  bicuspid  forceps — safety 403 

148.  Upper  molar  forceps — right  and  left 403 

149.  Upper  molar  forcepis 404 

150.  Upper  molar  forceps 404 

151.  Upper  molar  forceps — for  either  side 405 

152.  Cow-horn  forceps— right  and  left 40G 

153.  Upper  molar  cow-horn  forceps — either  side; 407 

154.  Lower  molar  forceps — either  side 407 

155.  Lower  cow-horn  forceps 408 

156.  Lower  cow-horn  forceps — right  side 408 

157.  Lower  cow-horn  forceps — leftside 408 

158.  Wolverton's  forceps 409 

159.  Hutchinson's  forceps 409 

160.  Upper  dentes  sapientise  forceps 410 

161.  Physick's  forceps 410 

162.  Forceps  for  wisdom-teeth — lower  side 411 

163.  Fulcrum  forceps 412 

164.  Fulcrum  forceps 412 

165.  Fulcrum  forceps.... 412 

166.  Fulcrum  forceps 413 

167.  Elevators  used  in  extracting  roots  of  teeth 413 

168.  Relation  of  fractured  roots  to  alveolar  line 414 

169.  Stellwagen's  incising  forceps 415 

170.  Stellwagen's  incising  forceps 416 

171.  Screw  for  extracting  roots  of  teeth 416 

172.  Dubs's  screw  forceps 417 

173.  HuUihen's  screw  forceps 417 

174.  Eoot  forceps 418 

175.  Eoot  forceps 418 

176.  Root  forceps 418 

177.  Root  forceps 418 

178.  Eoot  forceps 419 

179.  Root  forceps 419 

180.  Root  forceps 419 

181.  Anomalous  teeth '. 419 

182.  Anomalous  teeth 421 

1'83.  Anomalous  teeth 421 

184.  Spray  apparatus — hand  instrument 429 

185.  Spray  apparatus — foot  instrument 430 


LIST  OF  ILLUSTRATIONS.  xvii 

FIG.         .  PAGE 

186.  Pivoted  tooth 456 

187.  Excising  forceps 4-58 

188.  Excising  saw 459 

189.  Pivot  files 459 

190.  Hand-lathe 4G0 

191.  Foot-lathe 461 

192.  Impression  tray 468  • 

193.  Impression  tray 468- 

194.  Impression  iv<x\ 469  ' 

195.  Irregular  denture 481 

196.  Irregular  denture 481 

197.  White's,  J.  D.,  correcting  plate 483 

198.  "VVestcott's,  A.,  correcting  plate 483 

199.  Irregular  denture 485 

200.  Correcting  bars 485 

201.  Irregular  denture  with  correcting  band  applied 485 

202.  Irregular  denture 486 

203.  Correcting  appliances 486 

204.  Correcting  appliances 486 

205.  Corrected  denture > 487 

206.  Metal  cap  for  front  teeth 488 

207.  Irregular  articulation 488 

208.  Inferior  maxilla — showing  angle  at  diiierent  ages 489 

209.  Occipito-mental  sling 490 

210.  Corrected  denture 491 

211.  Ketaining  plate 491 

212.  Wedged  denture 492 

213.  Expanding  screw 494 

214.  Instruments  employed  in  scaling  teeth 503 

215.  Denudation  of  teeth 505 

216.  Denudation  of  teeth 505 

217.  Salivary  fistule 508 

218.  Operation  for  fistule 511 

219.  Tonsil  glands 516 

220.  Hypertrophied  tonsil 520 

221.  Tonsillotome -523 

222.  View  of  the  air-tubes  527 

223.  Uvula  scissors .530 

224.  View  of  gums  inflamed  by  vulcanite  plate .543 

225.  View  of  case  of  general  hypertrophy  of  gums 545 

226.  View  of  chronic  ulitis,  with  recession 546 

227.  Sequestrum  after  measles 582 

228.  Appearance  of  patient  with  phosphor-necrosis 593 

229.  Crossed  and  knotted  bandage 600 

230.  Barton's  bandage,  and  jaw-fracture  dressing 628 

231.  Gibson's  bandage 629 

232.  Garretson's  bandage 630 

233.  Gunning's  first  splint 631 

284.  Gunning's  second  splint 631 

B 


xviii  LIST  OF  ILLUSTRATIONS. 

FIG.  PAGE 

235.  Gunning's  third  splint 632 

236.  Gunning's  fourth  splint 632 

237.  Complete  dislocation  of  jaw 637 

238.  Manipulations  in  dislocation 641 

239.  Yertico-niontal  cap 642 

'240.  Superficial  ranula — showing  treatment  by  seton 699 

'241.  Deep-seated  ranula 700 

;242.  Microscopic  view  of  cancer-cells — after  Paget 770 

243.  Amputation  of  tongue  by  strangulation ■. 796 

:244.  Transfixing  ligature 797 

'245.  Chassaignac's  ecraseur 798 

'.246.  Wire  ecraseur  798 

247.  Kegnoli's  operation  for  ablation  of  tongue 799 

248.  Syme's  operation  for  ablation  of  tongue 799 

249.  Epulic  tumor 820 

250.  Odonto-periosteal  tumor 821 

251.  Ulitic  tumor 821 

252.  Epnlic  tumor 827 

253.  Epulic  tumor 827 

254.  Epulic  tumor 827 

255.  Epulic  tumor 827 

256.  Epulic  tumor 827 

257.  Operations  on  lower  jaw 830 

258.  Odontoma 835 

259.  Odontoma 836 

260.  Microscopic  section  of 836 

261.  Hyperostosis 839 

262.  Osseous  tumor 842 

263.  Hyperostosis  of  tuberosity  of  maxilla 843 

264.  Microscopic  section  of. 845 

265.  Odontocele 850 

266.  Dentigerous  tumor 856 

267.  Microscopic  section  of 857 

268.  Dentigerous  tumor 859 

269.  Dentigerous  tumor 860 

270.  Dentigerous  tumor 861 

271.  Microscopic  section  of 862 

272.  Antral  cyst 870 

273.  Secondary  cj-st  of  antrum 872 

274.  Osteo-sarcomatous  tumor 894 

275.  Cysto-sarcoma 894 

276.  Nodulated  tumors 907 

277.  Hard  cancer-cells 910 

278.  Encephaloid  tumor 915 

279.  Encephaloid  tumor 916 

280.  Microscopic  view  of  cells  in  soft  cancer 916 

281.  Cells  seen  in  soft  cancer 916 

282.  Dotted  nuclei  of  soft  cancer 916 

283.  Clustered  nuclei  of  soft  cancer 917 


LIST  OF  ILLUSTRATIONS.  xix 

FIG.  PAGB 

284.  Caudate  cells  of  firm  encephaloma 917 

285.  Small  elongated  cells  of  enoejjhaloma 917 

286.  Indurated  epithelioma 918 

287.  Ulcerating  epithelioma 918 

288.  Epithelioma  of  gum 919 

289.  Sebaceous  tumor  of  face 933 

290.  Cartilaginous  cysts 935 

291.  Lobulated  lipomatous  tumor 936 

292.  Microscopic  structure  of  an  adipose  tumor 936 

293.  Fatty  tumor  from  under  the  tongue 936 

294.  Venous  tumor 939 

295.  Strangulated  tumor  on  lip 940 

296.  Transfixed  tumor 941 

297.  Transfixed  tumor 941 

298.  Keloid  boa  of  neck 950 

299.  Elliptical  incision  in  the  operation  for  hare-lip 957 

300.  Hainsby's  compress 960 

301.  Hare-lip  operation 963 

302.  Hare-lip  operation 964 

303.  Double  hare-lip 965 

304.  Projection  of  intermaxillary  bone 969 

305.  Complicated  hare-lip 970 

306.  Complicated  hare-lip 970 

307.  Complicated  hare-lip 970 

308.  Complicated  hare-lip 970 

309.  Complicated  hare-lip 971 

310.  Hare-lip  pins  and  ligatures 972 

311.  Mouth-stretcher 978 

312.  Study  in  lip  operations 983 

313.  Study  in  lip  operations 985 

314.  Study  in  lip  operations  985 

315.  Study  in  lip  operations 986 

316.  Study  in  lip  operations 986 

317.  Study  in  lip  operations 987 

318.  Study  in  lip  operations 988 

319.  Study  in  lip  operations 989 

320.  Study  in  lip  operations 989 

321.  Study  in  lip  operations 989 

322.  Study  in  lip  operations 990 

323.  Plastic  operation  on  face 992 

324.  Study  in  rhinoplasty  1000 

325.  Study  in  rhinoplasty 1001 

326.  Study  in  rhinoplasty ." 1001 

327.  Study  in  rhinoplasty 1001 

328.  Study  in  rhinoplasty 1003 

329.  Study  in  rhinoplasty 1002 

330.  Study  in  rhinoplasty 1006 

331.  Study  in  rhinoplasty 1007 

332.  Mouth  gag 1029 


XX  LIST   OF  ILLUSTRATIONS. 

FIG.  PAGE 

333.  Study  in  obturators 1037 

334.  Study  in  obturators 1008 

335.  Study  in  obturators 10-iO 

336. 'Study  in  obturators 1041 

337.  Study  in  obturators 1042 

338.  Study  in  obturators 1043 

339.  Study  in  obturators 1044 

340.  Study  in  obturators 1045 

341.  Study  in  obturators 1046 

342.  Face  without  nose 1049 

343.  Palatine  arch  with  obturator 1050 

344.  Artificial  nose 1052 

345.  Attachment  of  artificial  nose 1052 

346.  Artificial  nose  in  place 1053 

347.  Face  without  nose  and  superior  lip I'.lv, 

348.  New-made  lip 1056 

349.  Artificial  nose  in  place 1057 

350.  Artificial  nose,  showing  springs  for  retaining 1057 

351.  Mouth-stretcher  applied 1066 

352.  Mouth-stretcher  applied 1066 

353.  Surgical  anatomy  of  inferior  maxillary  nerve 1070 

854.  Incision  for  exposing  coronoid  process  of  lower  jaw 1071 


PLATES. 


I.  Anomalies  in  dentition 157,  158 

II.  Anomalies  in  dentition 160,  161 

III.  Anomalies  in  dentition 163,  164 

IV.  Dental  tumors,  with  microscopic  appearance  of 166 

V.  Anomalies  in  dentition 1G7,  169 

VI.  A  view  of  the  anatomy  of  the  side  of  the  face  and  of  some  of 

the  operations  practiced  on  it 515 

VII.  A  view  of  operations  performed  on  the  trachea 531 

VIII.  Appearanceandpositionof  some  of  the  tumors  seen  about  the  neck     931 

IX.  Hare-lip  and  atresia  oris 972 

X.  Plastic  surgery  of  lips 972 

XII.  Operations  on  the  tongue 795 

XIII.  Operations  in  rhinoplasty 990 

XIV.  Khinoplastic  and  cheiloplastic  operations 1003 

XV.  Khinoplastic  operations 1005 

XVI.  The  operation  of  staphyloraphy 1024 

XVII.  Kesections  of  maxilla 1061 


STUDENT'S    PREFACE. 


Special  surgery,  like  surgery  proper,  considers  and  treats  of  dis- 
ease as  contradistinctiv^e  to  ease. 

Ease  implies  the  normal  condition.  A  body  in  a  state  of  ease  is 
in  harmony,  part  with  part,  no  source  of  derangement  existing  to 
interfere  with  its  functional  life. 

Dis-ease,  in  the  greatest  breadth,  as  in  the  narrowest,  of  its  signi- 
fication, has  its  meaning  in  a  single  word, — ^'  irritation. ^^ 

Irritation  is  that  derangement,  of  any  and  every  nature,  which 
ensues  from  the  presence  of  an  irritant. 

An  irritant  is  that  which  irritates,  or  which  interferes  with  func- 
tion. What  an  irritant  may  be, — how  it  deranges, — how  it  inter- 
feres with  ease,  producing  disease, — how  we  are  to  antagonize  it 
and  its  results, — this  is  the  province  of  the  science  we  study. 

Imprimis :  A  student  will  look  most  simply,  yet  truthfully  and 
fully,  at  the  subject-matter  of  our  study,  thus :  Whenever  a  patient 
presents  himself  with  his  complaint,  no  matter  what  may  be  the 
character  of  the  lesion,  where  or  how  situated,  the  trouble  has  its 
origin  in  the  presence,  directly  or  indirectly,  of  some  agent  of  irri- 
tation. This  appreciated,  a  deduction  naturally  follows, — that  the 
relief  and  cure  of  disease  should  lie  in  the  discovery  and  removal  of 
a  cause  inducing  it. 

An  irritant  is  an  offense  of  many  aspects.  It  may  be  a  simple 
splinter  pricking  the  finger,  easy  of  recognition  and  treatment,  or  it 
may  be  some  adventitious  deposit  in  a  viscus,  which  the  nicest 
refinement  of  modern  diagnosis  shall  not  enable  us  to  discover. 

The  study  of  medicine  comprehends  much.  If  it  begins  with  the 
splinter,  it  has  its  domain  bounded  alone  by  the  widest  investigations 
of  physics.  A  surgeon  is  full,  in  proportion  as  he  comprehends  from 
the  central  principle  outward.  To  pull  a  splinter  from  a  wounded 
finger,  to  lift  a  mote  from  an  eye  irritated  through  its  presence, — 

2  (17) 


18  STUDENT'S  PREFACE. 

these  ai"e  surgical  performances,  simple,  it  is  true,  yet  are  applica- 
tions, in  such  direction,  of  kaowledge  We  may  pass  outward  to  the 
inflamed  jaw  which  the  carious  tooth  worries  and  frets  by  its  pres- 
ence, and,  with  the  comprehension  of  an  effect  from  a  cause,  extract 
the  offending  organ,  and  from  his  dis-ease  the  patient  is  immediately 
restored  to  ease.  We  find  a  bone  necrosed,  and  are  instruments  of 
good  to  a  sufferer  so  far  as  our  attainments  shall  direct  in  the  means 
to  his  relief.  We  meet  with  an  arm  or  a  leg  fractured,  and  as  we  shall 
comprehend  the  meaning  of  such  accident  in  its  relation  with  the 
laws  of  the  human  organism,  so  we  restore  the  member  to  useful- 
ness, or  complete  its  destruction. 

From  evident  causes  of  disease  an  observer  finds  himself  led  to 
an  appreciation  and  judgment  of  the  occult  and  complicated.  Judg- 
ment grows  an  offspring  from  knowledge,  and  becomes  a  power  as 
reliable  as  that  which  has  emanated  it ;  thus,  through  the  seen,  is 
the  unseen  not  unfrecjuently  to  be  recognized. 

When  the  body  is  in  a  state  of  ease,  we  say  it  is  in  a  physiological 
state  ;  when  in  dis-ease,  we  pronounce  the  pathological  condition. 
Pathology  is  a  study  having  its  basis  in  physiology,  and  physiology 
is  a  science  having  its  foundation  in  anatomy.  The  animal  body  is 
a  machine.  To  comprehend  a  machine,  one  must  analyze  it, — take 
it  apart,  look  into  and  recognize  piece  by  piece  its  construction, 
know  where  this  and  that  fit,  and  what  is  the  harmony  of  the  asso- 
ciation. This  is  anatomy.  A  man  may  never  be  a  surgeon,  gen- 
eral or  special,  who  begins  not  with  such  analysis  as  his  foundation. 

A  knowledge  of  the  construction  of  a  machine  enables  one  to  under- 
stand the  principles  and  nature  of  the  movements  pertaining  to  the 
construction,  let  these  be  what  they  may.  That  which  is  the  life — 
the  movement — of  a  machine,  is  its  physiology :  one  may  scarcely  be 
expected  to  possess  the  ability  to  appreciate  the  wrong-going  of  a 
machine  who  knows  not  what  is  the  right-going  of  it.  Physiology, 
then,  is,  to  the  surgeon,  a  preliminary  stud}',  succeeding,  with  him, 
Anatomy. 

Pathology  is  the  expression  of  Irritation  ;  irritation  we  recognize 
as  the  signification  of  disease.  Having  familiarized  himself  with 
the  anatomy  and  physiology  of  a  human  being,  a  student  is  prepared 
to  appreciate  collectively,  in  association,  or  distinctively,  any  fact  or 
facts  presented  to  him  in  surgery. 

By  Irritation,  we  have  understood  an  effect  which  follows  from  the 
presence  of  an  irritant.      The  sources  and  causes  of  irritation  a 


STUDENTS  PREFACE.  19 

writer  might  scarcely  attempt  to  enumerate.  Food,  which  to-day 
digests  and  nourishes,  to-morrow  ferments  and  poisons ;  the  glisten- 
ing stone,  wiiich  in  the  morning  the  child  delights  to  show  its  play- 
mates, in^the  afternoon  kills  its  owner  by  falling  into  his  windpipe; 
water  refreshes,  or  it  may  scald  or  drown  ;  sunshine  affords  life, 
or  burns  and  depresses  to  death ;  years  grow  vigor  and  breed 
debility.  We  may  fairly  embi'ace  this  aspect  of  our  subject  only  by 
recognizing  that  there  is  nothing  which  is  incapable  of  becoming  a 
source  of  irritation.  As  the  reflection  of  part  upon  part  is  concerned, 
we  instance  the  deranged  stomach,  the  congested  liver,  the  parasite- 
loaded  bowel,  the  stone  in  the  bladder,  the  calculus  in  the  kidney, 
the  tumor  over  the  nerve. 

The  phenomena,  however,  which  designate  and  characterize  the 
presence  of  an  irritant, — these  we  are  to  comprehend  and  appre- 
ciate. 

The  presence  of  a  source  of  irritation  finds  primary  expression  in 
a  disorder  of  sensation ;  such  disorder  being  of  an  extent  and  char- 
acter corresponding  with  the  nature  of  the  offending  agent,  or  the 
idiosyncrasy  of  the  individual.  Disordered  sensation  may  be  gen- 
eral or  local :  shock,  from  the  reception  of  sudden  tidings,  illustrates 
the  first ;  the  tingling  half-frozen  fingers  are  an  example  of  the 
second.  Disordered  sensation  may  be  attended  or  unattended  with 
the  feeling  of  pain ;  pain  in  disordered  sensation  originates  in  me- 
chanical pressure  or  other  source  of  offense  arising  from  the  lesion. 

Evidences  of  irritation  are,  in  their  relationship,  direct  or  indirect. 
An  aching  tooth  may  express  itself  by  a  neuralgia  seated  in  the  dura 
mater,  or  on  any  branch  of  the  trigeminus ;  a  worried  liver  may 
speak  its  complaint  in  the  subscapular  Ijranches  of  the  cervical 
plexus ;  a  gorged  stomach  will  not  unfrequently  look  its  distress 
from  an  enlarged  and  fixed  pupil. 

The  effects  of  an  irritant  acting  upon  a  part  are  apt  to  have  a 
history  modified  by  the  temperament,  or  state  of  force,  of  the  indi- 
vidual. A  blow  received  by  a  delicate  woman  upon  the  lower  jaw, 
breaks,  perhaps,  that  bone ;  received  by  the  scrofulous  child,  it  in- 
flames and  kills  the  part;  the  same  force  of  offense  to  a  vigorous 
farm-laborer  scarcely  elicits  recognition.  Phosphorus,  while  utterly 
destructive  to  the  bone  of  one  workman  in  the  match-factory,  is  fully 
resisted  by  his  fellow  laboring  at  a  neighboring  table.  A  single 
carious  tooth  in  the  jaw  of  one  person  may  provoke  necrosis  ;  in 
another,  a  mouthful  similarly  affected  fails  of  such  an  end.  The 
slightest  extent  of  irritation  may  suSice,  in  the  plethori«,.  to  excite 


20  STUDENTS  PREFACE. 

an  inflammation  ;  in  the  lymphatic  man  it  takes  a  very  great  amount 
to  elicit  from  the  sanguineous  system  even  a  response.  In  the  case 
of  the  non-cognizable  irritants,  as  the  epidemic,  endemic,  and  infec- 
tious poisons,  such  modification  finds  most  marked  illustration.  One 
individual  shall  be  so  susceptible  as  to  succumb  without  resistance^ 
a  second  finds  his  system  offering  long-continued  battle  ;  a  third 
seems  not  at  all  susceptible.  We  are  to  infer,  then,  that  the  evi- 
dences of  the  presence  of  an  irritant  have  a  much  modified  expres- 
sion. 

We  pass  here  to  the  observation  of  the  common  expressions;  and, 
that  we  shall  possess  an  illustration  recognizable  by  any  student, 
we  consider,  first,  the  simple  mechanical  irritant. 

A  man,  for  example,  receives  a  shot  in  his  body.  Here,  as  the 
primary  condition,  there  is  a  break  of  continuity  in  the  tissues,  asso- 
ciated with  more  or  less  injury.  How  will  the  system  endure  and 
treat  this  offense  ?  First,  recognition  is  received  by  the  sonsorium 
through  the  medium  of  the  injured  sensory  nerve-filaments ;  pain  is 
felt,  and  functions  are  interfered  with  according  to  the  extent  and  na- 
ture of  the  injury.  The  sensorium,  immediately  responsive,  issues 
directions  for  the  expulsion  of  the  offending  agent ;  the  means  to  this 
end  is  to  be  the  loosening  of  the  body  and  the  floating  of  it  from  its 
lodgment.  This  applies  to  every  description  of  foreign  substance, 
whether  it  has  come  from  without,  or  should  develop  within,  as  in 
the  case  of  dead  bone  or  calculi.  First,  it  is  perceived  that  neigh- 
boring parts  increase  in  redness.  This  is  the  result  of  a  superflow 
of  blood  to  the  parts.  It  is  termed,  technically,  "  simple  vascular 
excitement."  This  flow  increases,  until  at  length  everv  vessel  be- 
comes engorged.  This  is  the  state  of  "congestion."  A  succeeding 
stage  is  the  stoppage  of  this  mass  of  blood, — "stagnation."  Nu- 
trition now  ceases,  the  parts  die,  and,  in  a  stream  of  pus  "  suppura- 
tion," the  agent  of  the  offense  and  its  immediate  envelope  are  floated 
away.  Thus,  Nature  has  relieved  herself,  and,  the  process  of  repair 
taking  the  place  of  the  destructive  process,  the  lost  part  may  be 
quickly  restored. 

The  action  thus  hastily  described  is,  however,  a  rule  with  excep- 
tions. A  foreign  body  may  become  encysted, — that  is.  Nature  may 
find  her  easiest  and  quickest  relief  by  enveloping  the  offense  in  a 
cyst,  and,  while  affording  it  lodgment,  yet  shut  it  out  from  all  rela- 
tionship with  the  life  surrounding  it.  As  examples  of  such  relief, 
cases  are  on  record  of  balls  remaining  without  discomfort  in  the 
human  body  for  years. 


STUDENTS  PBEFACE.  21 

The  presence  of  a  foreign  body  may  be  tolerated  through  other 
natural  provisions.  Thus,  a  calculus  forming  in  a  duct  may  have 
such  duct  enlarge  the  provisions  of  its  carrying  copacity  so  that  the 
body  shall  not  complete  an  obstruction.  Illustrations  of  this  pro- 
vision e.xist  in  the  case  of  gall  and  salivary  obstructions.  A  stone 
in  the  bladder  will  excite  that  extent  of  vascularity  which  shall 
overbalance  the  mechanical  attenuation  and  thinning  through  a 
resulting  hypertrophy,  thus  antagonizing  the  destructive  influence. 

A  foreign  body  may  be  cast  out  through  the  offices  of  a  functional 
activity  excited  in  the  parts  invaded:  the  lachrymal  secretion  wash- 
ing a  particle  from  the  eye  furnishes  an  illustration. 

Irritation,  when  existing  as  an  element  in  the  process  of  the 
expulsion  of  an  offending  body,  is  classible  as  the  first  of  the  inflam- 
matory phenomena.  Thus,  we  study  inflammation  under  six  asso- 
ciated aspects : 

1.  Irritation. 

2.  Simple  vascular  excitement. 

3.  Active  congestion. 

4.  Stagnation. 

5.  Suppuration. 

6.  Repair. 

The  associate  characteristics  by  which  we  distinguish  the  existence 
of  inflammation  are  redness,  heat,  pain,  swelling,  and  granular  activity. 

The  study  of  inflammation  is  the  completion  of  the  circle  of  the 
meaning  of  irritation.  No  man  may  know  of  surgery  but  as  he 
knows  of  inflammation. 

General  irrifaf ion. — Viewed  from  the  medical  stand-point,  we  are 
to  assume  the  existence  within  the  human  system  of  a  force  which 
we  term  excitability.  Of  this  force  we  affirm,  as  of  the  blood, 
that  there  is  just  so  much,  and,  like  unto  the  blood,  that  it  is 
harmonious  and  proportionable  in  its  disposition.  This  excita- 
bility, vis  vitse,  is  a  correlating  essence  or  thing,  and  is  consequently 
to  be  considered  as  allied  with  matter.  The  correlating  of  this  vis 
vitae  differs  in  no  respect,  save  in  manner,  from  the  principle  employed 
in  converting  beat  into  steam,  and  steam  into  momentum,  and  mo- 
mentum back  again  into  heat;  and  the  life  itself  differs  not  in  kind 
from  that  which  is  the  cohesive  force  of  a  weed. 

Physical  life  is  a  phenomenon, — this,  and  nothing  more.  What, 
from  lack  of  better  understanding,  we  term  the  vis  vitse,  is  to  have 
from  us  no  more  respect,  nor  is  it,  as  the  physician  is  to  estimate 


22  STUDENTS  PBEFACE. 

it,  less  an  anatomieo-physiological  thing,  than  is  a  bone,  a  muscle, 
or  a  brain-cell.  As  physicists,  we  consider  it  physiologically,  and 
through  such  consideration  we  direct  and  circumvent  its  vagaries  as 
we  do  that  of  the  blood  in  its  associative  inflammatory  perversions.* 

Excitability  we  are  to  accept  as  the  vivifying  principle.  As  this 
force  exists  in  a  correlative  fullness,  man  lives;  as  it  diminishes  in 
him,  so  he  proportionably  dies.  Ample  illustration  of  such  truth 
exists  in  the  matter  proper,  as  we  recognize  it,  of  the  body.  In  what 
we  term  the  physiological  state  we  find  the  act  of  life-renewal  a  per- 
fect process  ;  the  organism  is  maintained  in  its  integrity.  In  sick- 
ness, correlation  is  deranged,  the  circle  is  broken,  and  that  matter 
which  is  constantly  passing  from  the  body  is  not  replaced  by  that 
which  in  the  normal  life  is  constantly  coming  to  it;  hence  the  wast- 
ing,— the  decrease.  It  is  the  classic  legend  of  the  pelican  constantly 
repeating  itself, — the  bird  feeding  its  offspring  with  its  own  body, 
having  in  its  turn  no  nourishment. 

Excitability — i.e.  the  vis  vitse,  the  vitalizing  principle — is  not  to 
be  confounded  with  nerve-matter,  or  with  the  sanguineous  system, 
or  with  any  special  relation.  It  is  Force:  a  something  in  itself, — in 
abstracto.  Negatively,  we  recognize  it  in  its  going  out  from  organic 
tissue.  First,  its  existence  in  the  muscular  sense,  say  of  a  living 
bullock ;  then  its  complete  absence  in  flesh  which  is  called  putres- 
cent. In  the  meat  of  the  shambles  we  see  that  extent,  relation,  and 
conjunctive  quantity  of  it  which  is  the  mean  between  that  which 
pertains  to  moving  life  and  disintegrative  death.  In  other  words, 
we  see  in  the  meat  the  relation  between  force  and  matter,  in  that  the 
law  of  the  transformations  and  transmigrations  of  the  one  is  the 
common  law  of  both. 

The  treatment  of  disturbance  of  excitability  through  nervines 
finds  its  explanation,  I  conceive,  in  a  deadening  impression  made  on 
the  instruments  of  its  expression  ;  as,  for  example,  in  the  sanguineous 
system  we  may,  through  the  application  of  ether-spray  or  other 
means  of  cold,  so  contract  the  capillaries  of  a  part  that,  in  defiance 
of  the  most  urgent  protest  of  a  fever-irritated  heart,  we  utterly  abro- 
gate the  office  of  these  vessels,  and,  so  far  as  the  parts  are  concerned, 
deny,  ipso  facto,  the  power  to  the  organ  of  expression. 

Accepting,  then,  the   premises  of  the  existence  of  excitability. 


*  The  author  denies  a  right  to  criticise  this  passage  except  to  him  who 
recognizes  a  distinction  assumed  between  the  Ego  and  the  physical  man. 


STUDENT'S  PREFACE.  23 

without  a  present  consideration  or  speculation  as  to  what  it  is,  we 
find  our  first  expression  of  systemic  irritation  in  the  perversion  of 
the  equilibrium  of  this  something*.  General  irritation  is  super- 
excitation.  It  has  been  maintained  that  as  the  body  contains  just 
so  much  excitability,  and  that  this  expresses  fullness,  there  cannot 
be  such  a  thing  as  general  excitation ;  but  this  is  certainly  a  fallacy, 
for  as  well  might  we  say  that  the  oceans  of  water  could  not  be  roused 
from  their  normal  calm  and  lashed  into  rolling  waves.  It  does  not 
seem  at  all  necessary  to  fall  back  on  the  premise  that,  although  the 
system  has  such  limited  amount  of  excitability,  the  full  force  of  it  is 
not  called  into  play  in  health,  and  that  general  irritability  means  the 
provocation  into  action  of  the  reserve.  In  fever,  the  circulation  is 
in  a  state  of  general  disturbance  or  irritability,  and  of  this  fluid  there 
is  in  a  body  just  so  (proportionable)  much;  but  here  we  are  not  at 
fault  in  reading  the  phenomenon ;  only,  however,  are  we  not  so, 
because  we  deal  with  a  cognizable  thing. 

That  excitability  uses  primarily  the  nervous  system  as  the  instru- 
ment of  its  expression  seems  fully  demonstrated  in  such  metastatic 
transfers  of  inflammatory  phenomena  as  are  found  in  tlie  relation 
of  parotitis  and  orchitis;  while  a  negative  proof,  having  the  wide 
signification  of  exhibiting  the  comparative  separability  of  the  Ego 
from  the  common  life  of  a  man,  is  seen  in  the  exemption  of  the  nerves 
of  special  sense  from  the  uses  of  organic  life.  To  make  an  example: 
we  may  so  benumb  the  fingers  that  incisions  can  be  made  without 
pain,  yet  during  the  process  find  the  special  sense  of  touch  unim- 
paired ;  or  we  may  make  another  demonstration  in  witnessing  the 
painless  cutting,  lacerating,  or  burning  of  a  nerve  of  special  sense 
while  beholding  the  writhings  which  attend  the  wounding  of  a  part 
supplied  from  the  excito-motor  system. 

Recognizing  thus  the  existence  of  a  common  life-principle  and  its 
subjectiveness  to  general  supei'-excitation,  we  are  prepared  to  pass, 
with  sounder  judgment,  to  the  expressions  of  irritability  as  mani- 
fested in  its  employment  of  the  resources  of  the  sanguineous  system 
in  the  perversions  known  as  inflammatory. 

Fever,  the  expression  of  general  excitability,  seems  to  partake  of 
the  nature  of  a  reactive  process ;  preceded  by  depression  so  great,  it 
may  be,  as  to  amount  to  chill;  its  division  into  the  three  stages  of 
invasion,  reaction,  and  resolution  are  commonly  very  marked. 

Invasion. — This  maybe  characterized  by  a  distinct  chill  or  shiver- 
ing fit,  or  may  be  confined  to  general  malaise,  the  pulse  being- 
depressed,  the  appetite  defective,  with  indifference  to  food,  and,  it 


24  STUDENTS  PREFACE. 

may  be,  nausea;  the  surface  of  the  body  marks  a  diminished  tem- 
perature, and  is  not  unfrequently  shriveled,  presenting  the  peculiar 
roughness  known  as  the  cutis  anserina.  This  state  of  depression 
may  exist  from  a  few  hours  to  several  days. 

Eeaction. — The  second  condition  is  marked  by  increase  of  pulse, 
with  heat  that  soon  grows  into  a  sense  of  general  flush  ;  appetite 
still  further  diminishes  ;  the  tongue  most  likely  becomes  furred  ;  the 
bowels  are  constipated  ;  thirst  grows  a  prominent  symptom  ;  the  tem- 
perature naturally  finds  an  elevation  from  the  increasing  rapidity  of 
circulation  and  cell-change,  the  pulse  running  up  not  unfrequently 
as  high  as  110°.  The  overexcited  brain,  unable  to  perform  its 
functions,  deranges  more  or  less  all  expressions  of  which  it  is  the 
instrument;  taste  is  disagreeable,  or,  it  may  be,  is  lost;  the  seuses 
of  seeing  and  hearing  grow  preternaturally  sensitive ;  in  short,  up 
to  a  certain  point — the  point  of  exhaustion — the  system  at  large 
manifests  the  condition  of  super-excitation.  It  is  the  quiet  of  water 
disturbed  by  the  storm. 

Declining  stage. — In  fever,  disassociated  with  organic  derange- 
ment,— tbat  is,  in  the  "  ferveo"  of  simple  super-excitation  of  the  vis 
vitce, — the  return  to  the  equilibrium  is  gradual  and  without  the 
marked  phenomenon  of  a  crisis.  The  sense  of  heat  passes  away 
gradually,  thirst  diminishes,  the  skin  relaxes,  the  secretions  restore 
themselves,  and  in  a  greater  or  lesser  length  of  time,  depending  on 
the  temperament  of  the  individual,  the  harmony  of  functional  life  is 
restored.     It  is  the  disturbed  water  recovering  its  calm. 

General  Remarks. 

Fever  is  always  to  be  looked  on  as  disturbance  of  the  vitalizing 
principle.  A  fevered  patient  is  in  a  condition  analogous  to  a  burn- 
ing caudle  variously  disturbed  by  excess  of  carbon  or  oxygen ; 
boih  the  one  and  the  other  influence  aside  from  the  mean.  Depres- 
sion or  super-excitation  may  exist  within  the  limit  of  non-functional 
disturbance,  thus  demonstrating  the  ability  of  organic  life  to  endure 
without  ill  result  a  certain  extent  of  trespass.  The  state  of  invasion 
of  fever  is  to  be  viewed  as  that  condition  in  which  the  vis  vitse  is 
restrained.  Reaction  is  that  stage  in  which,  overflowing  or  break- 
ing such  restraint,  accumulation  exhibits  itself  in  consequent  super- 
excitation. 

Irritation  is,  or  is  not,  the  first  of  the  inflammatory  phenomena 
(locally  expressed),  according  as  it  is,  or  is  not,  followed  by  perver- 
sion of  the  circulatory  system.   When  irritation  has  excited  vascular 


STUDENT'S  PREFACE.  25 

derangement,  then  the  term  is  merged  into  the  varying  terms  ex- 
pressive of  the  stages  of  inflammatory  action.  Inflammation  is  not 
a  general,  but  a  local  condition,  and  its  normal  history  is  that  which 
tends  to  the  relief  of  irritation  through  the  expulsion  or  destruction 
of  a  cause  inducing  it,  as  is  illustrated  in  the  process  of  suppuration. 
Fever  and  inflammation,  as  thus  exhibited,  are  not  to  be  esteemed 
necessarily  coexisting  phenomena.  Fever  commonly  associates  itself 
with  inflammation,  being  aroused  by  such  condition  acting  as  an 
irritant,  while,  in  turn,  febrile  disturbance  may  readily  provoke  an 
inflammation  through  its  excitation  of  the  circulatory  system  ;  but 
it  is  frequently  enough  to  be  remarked  that  fever,  even  of  severe 
grade,  may  readily  run  its  course  without  inducing  that  extent  of 
vascular  perversion  which  yields  the  phenomenal  expression  of  in- 
flammation. 


DISEASES  OF  THE  MOUTH 


ASSOCIATE    PAKTS. 


CHAPTER    I. 

SURGICAL   ANATOMY   OP   THE    MOUTH   AND   FACE. 

Beginning  with  this  first  chapter,  the  author  assumes  a  famili- 
arity on  the  part  of  his  reader  with  the  principles  underlying  general 
medical  practice,  allusion  to  which  has  just  been  made, — a  familiarity 
which  is  alone  able  to  render  intelligible,  useful,  or  desirable  the 
study  of  any  one  of  its  specialties. 

In  a  work  on  oral  diseases  and  surgery,  a  source  of  ready  and 
accurate  reference  to  parts  involved  would  seem  to  be  an  essential. 
With  such  view  we  map  out,  as  accurately  as  the  photograph  and 
pencil  may  represent  nature,  all  such  parts  as,  surgically,  we  may 
have  to  deal  with  or  comprehend.  As — unless  with  the  very  expe- 
rienced— it  is  always  desirable  to  precede  an  operation  on  the  living 
with  a  test  performance  on  the  dead,  so  with  the  student  it  is  as 
desirable  to  found  the  comprehension  of  any  pathological  perversion 
on  an  understanding  of  normal  characteristics. 

In  presenting  these  photographs  of  the  various  parts  associated 
with  oral  surgery,  the  suggestion  may  be  added,  that  the  bones  rep- 
resented be  procured  and  laid  carefully  away  in  the  cabinet:  the 
assistance  of  their  silent  expressions  will  be  found  invaluable.  So 
far  as  the  soft  parts  are  concerned,  one  may  either  possess  them  in 
alcohol,  or,  what  is  even  better,  where  it  can  conveniently  be  done, 
may  make  it  a  point  to  dissect  them  yearly. 

Fig.  1  (exhibited  on  page  30)  represents  the  lateral  aspect  of 
the  face  ;  this  is  seen  to  form,  almost  accurately,  an.  oblong  square. 
A  modification  on  such  a  square,  however,  will  be  found  to  exist 
in  the  case  of  the  child,  where  the  ramus  of  the  inferior  maxil- 
lary bone  is  at  a  more  obtuse  angle  with  the  body;  also  in  the 
case  of  an  adult  with  prominent  os  frontis:  in  either  of  these  cases 
this  aspect  is  triangular.  Bounded  circumferentially  by  the  supra- 
orbital ridge  of  the  frontaL  bone,  the  nasal  process  of  the  superior 
maxillary,  and  the  malar  bones,  we  find  a  pyramidal  cavity,  the 

(29) 


30  ORAL  DISEASES  AND   SURGERY. 

orbital,  for  the  accommodation  of  the  organ  of  sight.     Looking  at 
the  natural  bone,  no  less  than  seven  pieces  are  observed  entering 

YiQ.  1. — Frokt  and  Lateral  Region  of  the  Skull. 


The  sKCLl  sees  partly  is  front  and  on  the  bight  side.  1,  frontal  bone;  2,  parietal 
bone-  3,  temporiil  bone,  its  squamoiis  portion;  4,  tlie  spbeuoid  bone,  tomporiil  surface  of 
its  great  win";  5,  etlimoid  bone,  its  orbital  surface;  6,  superior  maxillary  bone ;  7,  malar 
bone  :  8  lacbrvnial  bone ;  9,  nasal  bone ;  10,  inferior  maxillary  bono.  a.  orbital  plate  of 
the  frontal  lione ;  b,  temporal  surface  ;  c,  orbital  surface  of  the  great  wing  of  the  sphenoid 
bone-  d  mastoid  portion  of  tha  temporal  bone;  e,  orbital  surface  of  the  malar  bone; 
f,  orbital  plate  of  the  superior  maxillary  bone ;  g,  infraorbital  foramen  ;  /i,  mental  fora- 
men- i  symphysis;  j,  ramus;  k,  coronoid  process;  I,  neck  supporting  the  condyle  ;  m, 
angle ;  n,  lachrymo-nasal  duct. 

into  the  composition  of  this  cavity,  some  of  which  pieces  in  their 
relations  closely  affect  proceedings  in  oral  surgery :  for  example,  it 
will  be  seen  that  a  large  portion  of  the  floor  of  this  cavity  is  made 
up  by  a  process,  the  orbital,  which  is  a  part  of  the  superior  maxilla ; 
glancing  at  a  disarticulated  bone,  it  will  be  seen  that  this  process 
constitutes  as  well  the  roof  of  the  antral  sinus;  it  will  also  be 
found  to  be  a  very  thin  plate,  and  capable  of  being  easily  elevated 
or  depressed,  according  as  any  pressure  might  be  brought  upon  it 
from  below  or  above  ;  constituting  a  source  of  support  to  the  eye,  it 
will  also  be  seen  that,  where  it  is  possible,  it  should  be  left  undis- 
turbed in  operations  demanding  extensive  interference  with  the  bone 
of  which  it  is  a  part.  At  the  inner  inferior  aspect  of  the  cavity  a 
groove  will  be  observed,  the  lachrymal,  being  the  entrance  to  a  canal, 


AXATOMY  OF  THE  MOUTH  AND    FACE.  31 

the  ductus  ad  nasum,  earning  the  tears  from  the  orbit  to  the  inferior 
meatus;  the  outer  wall  of  this  canal,  which  it  is  most  important  to 
maintain  patulous,  is  made  up  by  the  inner  face  of  the  nasal  process, 
another  portion  of  the  superior  maxillary  bone.  Diseases  of  the  sinus 
not  unfrequently  react  on  the  eye,  and  to  such  an  extent,  that  blind- 
ness of  several  months'  standing  has  been  cured  by  the  extraction 
of  a  diseased  tooth-root  which  had  affected  the  antrum  to  its  engorge- 
ment. Closure  of  the  lachrymal  canal  is  almost  certain  to  occur  if 
the  nasal  process  becomes  inflamed,  and  such  inflammation  I  have 
frequently  met  with  as  the  result  of  an  odontocele. 

Immediately  below  the  inferior  boundary  of  the  orbit  is  seen  a 
foramen,  the  infraorbital,  for  transmission  of  the  infraorbital  branches 
of  the  fifth  nerve.  Passing  a  bristle  through  this  foramen,  it  is  seen 
to  emerge  in  the  groove  marked  on  the  floor  of  the  orbit, — the  infra- 
orbital groove  in  which  the  nerve  lies  in  its  passage  outward.  This 
groove  and  this  canal  are  both  in  the  maxillary  bone,  and  are,  alike 
with  the  ductus  ad  nasum,  influenced  by  its  diseases. 

The  canine  fossa,  seen  back  of  and  above  the  canine  tooth,  has,  as 
its  floor,  a  thin  plate  of  bone,  which  is  the  external  face  of  the  antrum, 
and  through  which,  if  it  should  be  found  necessary,  the  cavity  may 
be  easih'  entered. 

The  tuberosity  of  the  bone,  occupied  in  part  by  the  wisdom  tooth, 
and  marked  for  the  attachment  of  the  buccinator  muscle,  is  a  point 
of  surgical  interest, — it  being  not  at  all  uncommon  to  have  necrosis 
of  this  portion  of  the  bone,  the  result  of  an  ostitis,  induced  and  kept 
up  by  an  imprisoned  dens  sapientiae.  Standing,  as  is  seen,  at  an 
angle,  and  tubercle-like,  it  is  plainly  evident  that  neither  deformity 
nor  harm  would  result  from  its  separation  as  a  sequestrum. 

The  alveolar  pi'ocesses  are  remarked  to  constitute  quite  a  large 
part  of  both  the  superior  and  inferior  maxillary  bones.  These  pro- 
cesses, vascular  and  spongy,  subjected  to  all  irritations  residing  in 
diseased  teeth,  are,  without  doubt,  more  liable  to  take  on  patho- 
logical action  than  any  other  portion  of  the  ossa  corporae.  From 
the  alveolo-dental  periosteum  spring  epulic  outgrowths  of  various 
signification.  Sarcomatous  degeneration  finds  here  a  favorite  seat : 
simple  and  compound  cysts  are  very  familiar;  degenerative  ostitis 
is  "not  uncommon,  while  abscess  is  found  in  almost  every  mouth. 
The  mental  foramen,  seen  upon  the  inferior  maxilla,  a  little  anterior 
to  the  middle  of  the  body,  is  the  outlet  of  a  canal  traversing  the 
centre  of  the  bone,  and  conducting  beneath  the  teeth  the  dental 
artery  and   nerve.     The  size,  general  character,  and  inlet  of  this 


32  ORAL   DISEASES  AND   SURGERY. 

canal  should  be  observed,  as  not  unfrequentlj  injuries  to  tbe  artery 
require  that  the  canal  should  be  plugged,  either  as  foramina  are 
concerned  which  exist  beneath  each  tooth,  or  as  the  channel  proper 
is  interfered  with  in  operations  for  tumors  or  sequestra. 

Neuralgia  of  some  of  the  peripheries  of  the  inferior  dental  nerve 
makes  necessary,  occasionally,  its  section  within  the  canal.  To  get 
at  this  nerve,  requires  either  that  we  shall  extract  some  tooth,  and 
make  the  section  from  the  base  of  the  socket,  or  otherwise  that  a 
trephine  shall  be  used  from  the  outside.  The  easiest  mode  of  per- 
forming such  operations  is  to  be  observed,  as  relation  is  had  to 
location,  and  character  of  the  bone. 

The  association  of  the  teeth  with  their  spongy  processes  is  a  mat- 
ter which  should  receive  close  attention,  the  operation  for  their 
extraction  being  a  very  common  one.  These  processes,  if  examined 
in  a  number  of  bones,  will  be  found  to  vary  greatly  in  character:  in 
some  being  of  such  loose  structure  that  the  teeth  are  capable  of  the 
easiest  separation  ;  in  other  instances  being  so  firm  and  un3'ielding 
that  it  is  quite  an  impossibility  to  make  such  extraction  without 
more  or  less  fracture. 

The  number  and  shape  of  the  roots  of  the  teeth  are  to  be  ex- 
amined. A  knowledge  of  their  curves  contributes  much  to  skill  in 
their  removal.  Indeed,  no  one  but  the  experienced  can  appreciate 
how  much  easier  it  is  to  remove  the  teeth  with  than  without  such 
knowledge. 

The  nasal  bones,  forming  in  their  conjunction  the  nasal  arch, 
should  be  examined  in  their  relation  to  each  other  and  to  neigh- 
boring pieces.  Articulating  with  the  perpendicular  plate  of  the 
ethmoid,  it  has  not  unfrequently  happened  that  the  depression  of 
this  arch  from  a  blow  has  carried  the  crista  galli  into  the  sub- 
stance of  the  brain,  and  thus  produced  fatal  consequences.  The 
nasal  bones  are  frequently  the  seat  of  syphilitic  degeneration.  Their 
destruction  compels  the  falling  in  of  the  nasal  arch,  thus  yielding  the 
flattening  of  the  bridge  occasionally  observed, — one  of  the  most 
repulsive  of  deformities. 

The  incisive  fossa,  observed  between  the  anterior  nasal  spine  and 
central  incisor  teeth,  frequently  yields  its  floor  to  the  ravages  of 
necrosis  or  caries.  There  would  seem  to  be  here  less  vital  resistance 
than  in  other  parts  of  the  bone,  as  necrosis  of  a  tooth  is  almost 
necessarily  associated  with  disease  of  the  superficial  surface  of  its 
alveolus.  This  plate  is,  however,  quite  thin,  and  its  loss  seldom 
seems  of  much  consequence. 


ANATOMY  OF  THE  MOUTH  AND   FACE. 


33 


The  position  of  the  groove  for  the  passage  of  the  facial  artery, 
seen  on  the  inferior  maxilla,  is  to  be  noticed,  as  location  and  dis- 
tance from  the  angle  of  the  jaw  are  concerned, — the  control  of 
hemorrhage  about  the  lips  and  cheeks  being  here  secured  through 
simple  pressure  on  the  artery  as  it  passes  over  the  base. 

With  such  general  observation  of  the  surgical  features  of  the 
bones  in  conjunction,  we  pass  to  a  closer  stud}',  by  examining  the 
pieces  in  their  separate  capacities. 


Figs.  2  and  3. — Superior  Maxillary  Bone. 


w     « 


Superior  maxillary  boxe  of  the  left  side, 
outer  view.  1,  liofiy ;  2,  tuberosity;  3,  alve- 
olar border;  4,  orbital  plate  ;  5,  nasal  process  ; 
6,  nasal  notch ;  7,  nasal  spine ;  8,  lachrj-nial 
groove  ;  9,  entrance  of  the  infraorbital  canal ; 
10,  infraorbital  foramen;  11,  orifices  of  the 
posterior  dental  canals ;  12,  malar  process ; 
13,  articulation  for  the  internal  angular  pro- 
cess of  the  frontal  bone;  14,  incisor  teeth; 
15,  canine  tooth ;  16,  premolar  teeth  ;  17,  large 
molar  teeth. 


Superior  maxillary  boxe  or  the  left  side,. 
inner  view.  1,  nasal  surface  of  tlie  body;  2, 
surface  for  the  palate  bone ;  3,  alveolar  bor- 
der ;  4,  orbital  plate ;  5,  nasal  process ;  6, 
ridge  for  the  articulation  of  the  turbinated, 
bone ;  7,  nasal  spine ;  8,  groove  contributing 
to  form  the  lachrynio-nasal  duct ;  9,  maxil-- 
lary  sinus;  10,  palate  plate,  its  articulating, 
border  for  the  right  maxillarj'  bone;  11,  in- 
cisive foramen  continuous  with  the  naso-- 
palatine  canals;  12,  tuberosity;  13,  articular 
extremity  for  the  internal  angular  process 
of  the  frontal  bone;  14,  incisor  teeth;  15,. 
canine  tooth ;  16,  premolar  teeth ;  17,  large 
molar  teeth. 


Glancing  hastily  at  the  superior  maxillary  bone,  it  seems  like 
a  quadrilateral,  more  or  less  irregular,  solid  piece.  Looking  at  it 
critically,  and  from  the  surgical  stand-point,  we  find  it  to  consist  of  a 
series  of  processes,  so  grouped  together  as  to  form,  or  rather  inclose,. 
a  cavity  so  large  that  the  apparently  solid  body  is  found  to  be 
simply  a  shell.  This  cavity  of  the  shell  is  called  the  maxillary 
sinus,  or  the  antrum  of  Highmore.  It  is  a  very  irregular  cavity,, 
differing,  indeed,  in  shape  in  almost  every  bone  ;.  generally,  how- 


34  ORAL  DISEASES  AND  SURGERY. 

ever,  being  found  as  a  single  cave,  but  not  unfrequently  divided  into 
two  or  more  by  septi  of  bone  vertically  placed.  How  far,  in  the 
mean  of  cases,  the  cave  is  found  to  run  forward  and  bow  far  back- 
ward ;  what,  in  the  mean,  is  its  relation  to  the  roots  of  the  various 
teeth;  which  of  its  boundaries  are  the  thinnest;  are  matters  which, 
because  of  their  very  practical  signification,  are  worthy  of  being  most 
attentively  studied,  and  which  study  can  only  be  made  by  an  observa- 
tion of  many  bones.  Abscesses  of  the  roots  of  teeth  frequently  void 
themselves  into  this  cavity  :  we  are  to  understand  how  and  why, 
anatomically,  such  accidents  occur.  Engorgements  of  the  cavity, 
puruloid  or  dropsical,  bulge  outward  some  part  or  other  of  the 
circumferential  walls,  perhaps  throwing  the  eye  upon  the  cheek, 
projecting  the  canine  fossa,  or  making  a  tumor  on  the  palatine 
aspect  of  the  mouth:  we  are  to  understand  why  such  bulging,  from 
a  common  cause,  is  found  so  variously  situated,  or  why,  indeed, 
such  accumulations  exist  at  all. 

If  we  make  such  a  section  of  the  superior  maxillary  bone  as  to 
expose  the  antral  cavity,  we  shall  find  that  in  many  cases,  not  in- 
deed in  all,  its  floor  is  studded  with  little  hills;  break  into  one  of 
these  elevations,  and  you  will  find  that  it  is  a  very  thin  crust,  con- 
cealing the  root  of  some  tooth  or  teeth.  In  infrequent  cases,  a  root 
or  roots  will  be  found  projecting  into  the  cavity,  entirely  uncovered, 
save  with  the  membrane  which  had  existence  in  the  living  part.  Such 
a  view  explains  very  satisfactorily  dental  abscess  within  this  sinus. 

The  processes  which,  in  their  conjunction,  make  up  the  bone,  are 
four  in  number  :  the  alveolar,  the  palatine,  the  nasal,  and  the  malar. 

The  alveolar  process,  wedged  in  between  the  malar  and  palatine, 
constitutes  perhaps  the  greatest  bulk  of  the  bone.  Looked  at  from 
below,  it  is  found  to  l)e  excavated  into  cavities  or  pits,  correspond- 
ing with  the  character  and  number  of  the  roots  of  the  teeth  ;  these 
pits  are  termed  alveoli,  and,  in  the  recent  bone,  are  found  lined  with 
periosteal  tissue,  which  tissue  is  reflected  around  the  roots  of  the 
teeth,  forming  the  immediate  bond  of  connection.  lu  some  bones, 
the  structure  making  up  this  process  is  exceedingly  loose  and  spongy ; 
in  others  it  is  condensed,  and  cortical-like.  After  the  loss  of  the  teeth, 
this  process  is  removed  through  absorption ;  hence  the  approximation, 
in  old  people,  of  the  chin  and  nose.  Fractures  of  this  process,  the  re- 
sult of  falls,  blows,  or  attempts  at  tooth-extraction,  are  quite  common. 

The  tuberosity  of  the  bone  may  be  esteemed  as  the  posterior  ex- 
tremity of  the  alveolar  process,  being,  indeed,  not  unfrequently 
excavated  for  the  wisdom  tooth.     This  tubercle,  as  implied  in  its 


ANATOMY  OF  THE  MOUTH  AND   FACE.  35 

name,  is  simply  a  bulb  of  bone  ;  it  is  quite  vascular,  however,  and 
its  relation  to  the  posterior  tooth  subjects  it  to  sources  of  irritation 
which  not  unfrequently  results  in  its  inflammation  and  death. 

The  malar  process,  seen  projecting  from  the  middle  of  the  bone, 
is  a  rough,  serrated  facet  for  articulation  with  the  malar  or  cheek 
bone.  This  process,  in  front,  is  somewhat  concave ;  behind  it  has 
similar  curvature,  and  forms  part  of  a  fossa  known  as  the  zygo- 
matic. The  chief  point  of  interest  connected  with  it,  however,  lies 
in  the  character  of  the  suture  which  unites  the  maxillary  with  the 
malar  bone,  this  being  the  place  of  separation  in  amputation  of  the 
maxillary. 

The  nasal  process,  well  represented  in  the  drawing,  but  better 
studied  and  understood  from  observation  of  the  bone,  is  observed 
standing  above  the  orbital  surface.  Rising  from  the  anterior  facial 
aspect,  it  continues  upward  and  somewhat  backward,  until  it 
ends  in  a  rough  facet,  which  articulates  the  bone  with  the  frontal 
and  ethmoid,  and  assists  in  closing  in  the  anterior  ethmoidal 
cells.  Lined  in  the  recent  state  with  the  Schneiderian  membrane, 
which  membrane  is  continued  into  the  cells  of  the  ethmoid  and 
frontal  bones,  a  moment's  reflection  recognizes  the  meaning  of  that 
sense  of  fullness  so  common  about  the  anterior  base  of  the  cranium, 
when  inflammation  and  congestion  exist  in  the  nasal  canals.  Ex- 
ternally, the  face  of  the  process  is  concave,  thus  assisting  in  carrying 
out  the  natural  curve  of  the  lateral  aspect  of  the  nose ;  numerous 
foramina  are  also  observed  on  this  face,  for  the  passage  of  vessels. 
The  teudo  oculi  has  its  attachment  on  this  surface,  while  near,  on 
the  same  plane,  is  a  line  giving  origin  to  the  levator  labii  superior 
alaeque  nasi  and  orbicularis  palpebrarum  muscles.  Anteriorly,  the 
border  of  the  process  is  thin,  and  serrated  for  articulation  with  the 
nasal  bone.  Posteriorly,  it  is  thick,  and  hollowed  into  a  groove  for 
the  lodgment  of  the  lachrymal  sac  and  duct.  When  in  position,  in 
the  articulated  skull,  this  groove  is  converted  into  a  canal  by  annex- 
ation with  the  lachrymal  bone  ;  the  canal,  traced  downward,  is  found 
to  have  somewhat  of  an  hour-glass  shape,  being  considerably  con- 
tracted in  the  centre,  and  finally  terminating  at  the  inferior  meatus 
in  a  bell-shaped  opening.  A  little  tubercle,  the  lachrymal,  is  seen 
where  the  anterior  lip  of  the  groove  joins  the  orbital  surface  ;  this  is 
a  guide,  directing  the  bistoury  of  the  surgeon  into  the  canal,  when 
operations  for  its  stricture  are  demanded. 

The  orbital  surface  of  the  bone,  seen  before  in  its  articulative 
position,  is  here  observed  separate ;  falling  at  an  almost  direct  right 


36  OBAL  DISEASES  AND   SURGERY. 

angle  from  the  facial  aspect  of  the  bone,  it  is  remarked  by  such  rela- 
tion to  form  a  large  part  of  the  floor  of  the  orbital  cavity ;  while  looked 
at  from  the  cave  of  Highmore,  it  is  seen  to  form  as  well  the  roof  of 
this  vault.  When  broken,  or  held  against  the  light,  it  is  found  to  be 
almost  a  scale  in  thinness.  The  infraorbital  ridge  is  simply  the  rim 
made  by  the  bending  downward  of  this  orbital  surface.  Running 
along  the  free  edge  are  observed  three  distinct  articular  faces:  the 
outer,  for  the  palate  bone,  the  two  inner  for  the  orbital  or  plane  plate 
of  the  ethmoid  and  lachrymal  bones.  Below  the  rim,  or  infraorbital 
border,  is  seen  the  orbital  foramen.  Passing  a  bristle  into  this 
opening,  we  find  it  directed  to  the  groove  on  the  orbital  face,  the 
intraorbital.  Passing  the  bristle  now  from  the  groove  toward  the 
fornmen,  we  find  it  may  take  some  other  track,  and  not  appear  at 
the  opening.  Searching  for  an  explanation,  we  find  the  groove,  soon 
after  entering  beneath  the  ridge,  to  divide  into  two  canals,  one  of 
which  passes  to  the  face,  as  observed;  the  other  enters  the  antrum, 
and  transmits  across  this  cavity  the  nerves  and  vessels  designed  for 
the  nutrition  of  the  anterior  teeth. 

The  osseous  boundary  of  the  nose  is  seen  to  advantage  in  tliis 
drawing.  It  is  a  complete  curve,  and  gives  attachment  by  its 
continuous  crest,  or  edge,  to  the  cartilaginous  wings. 

The  zygomatic  surface,  seen  back  of  the  malar  process,  enters  into 
the  formation  of  the  fossa  of  that  name.  It  is  to  a  degree  convex, 
and  more  or  less  rough.  Dotting  its  surface  are  observed  a  number 
of  foramina;  these  are  entrances  to  canals,  the  posterior  dental, 
and  transmit  vessels  to  the  posterior  teeth,  all  situated  back  of  the 
canines.  At  the  lower  part  of  this  surface,  to  the  nasal  aspect  of  the 
tuberosity,  is  a  groove  destined  to  be  converted  into  a  canal  through 
an  articulation  with  the  palate  bone,  the  posterior  dental  groove. 
This  groove  or  canal  transmits  vessels  to  the  palatine  face  of  the 
bone,  and  is  seen  to  terminate  on  the  under  side  of  the  tuberosity. 

The  muscles  of  expression,  to  which  the  outer  surface  of  the  bone 
gives  origin,  are  numerous.  From  the  second  bicuspid  tooth  back 
to  the  tuberosity,  is  a  rough  line  for  the  trumpeter's,  or  buccinator 
(a  similar  line  existing  on  the  inferior  maxilla).  Above  this  first 
line,  and  below  the  malar  process,  certain  fibres  of  the  masseter  are 
attached.  Above  the  canine  fossa  is  the  origin  of  the  levator  anguli 
oris  ;  while  without  this,  toward  the  concavity  of  the  nose,  is  the  line 
for  the  compressor  naris.  In  the  incisive  or  myrtiform  fossa  is  seen 
the  origin  of  the  depressor  alse  nasi. 

Turning  now  toward  us  the  inner  face  of  the  bone,  we  see  the 


AI^ATOiMY  OF  THE  MOUTH  AND   FACE.  37 

fourth  process,  the  palatine.  This  process  starts  out  from  the  middle 
of  the  bone,  and  divides  it  into  two  unequal  parts.  Like  the  orbital 
plate,  it  is  at  right  angles  with  the  body,  and,  when  the  piece  is 
articulated,  is  seen  to  divide  the  nose  from  the  mouth,  constituting 
the  floor  of  the  first  cavity  and  the  roof  of  the  second.  Posteriorly, 
it  is  quite  thin,  and  articulates  with  the  palatine  process  of  the  palate 
bone.  Running  forward,  it  grows  thicker  aud  heavier,  and  ends  in 
the  anterior  nasal  spine.  Viewed  above,  its  surface  is  slightly  con- 
cave, to  form  the  floor  of  the  nares.  Externally,  it  becomes  merged 
into  the  body  of  the  bone;  internally  or  mesially,  it  rises  into  a 
ridge,  which  is  the  one  side  of  a  groove  receiving  into  articula- 
tion the  vomer.  A  bristle  passed  through  an  opening  in  the  pro- 
cess shows  the  position  of  a  canal,  the  anterior  palatine,  transmitting 
vessels  of  that  name,  which  find  entrance  into  the  oral  cavity  through 
the  incisive  foramen  seen  just  back  of  the  centre  tooth.  A  nerve,  the 
naso-palatine,  having  considerable  surgical  signification,  enters  the 
mouth  at  the  orifice  of  this  canal,  but  is  not  transmitted  by  it, 
having  a  canal  of  its  own  in  the  intermaxillary  suture.  The  three 
marked  points  of  surgical  interest  in  this  process  are — first,  the  fact 
of  its  forming  the  boundary  between  the  mouth  and  nose  ;  a  break 
in  its  continuity,  and  which,  unfortunately,  is  a  not  infrequent  acci- 
dent, throwing  these  two  cavities  into  one;  second,  the  nature  and 
relation  of  suture  with  the  palatine  process  of  the  palate  bone,  this 
being  the  line  of  separation  in  amputation;  third,  the  position  of 
entrance  of  the  naso-palatine  nerve,  paralysis  of  the  parts  supplied 
by  this  nerve  being  a  frequent  result  of  ill-applied  pieces  of  dental 
apparatus.  To  these  three  might  be  added  a  fourth,  the  position  of 
the  artery  occupying  the  posterior  palatine  canal,  an  artery  which 
is  sometimes  of  considerable  size,  and  which  might  easily  be  cut  by 
the  slip  of  a  lancet  applied  to  the  gum  of  a  wisdom  tooth,  or  in  the 
act  of  dividing  the  tendon  of  the  flexor  palati  where  it  curves  around 
the  hamular  process. 

The  other  features  observable  on  this  aspect  of  the  bone  are  with- 
out special  surgical  interest.  Above  the  inferior  meatus,  which  is 
the  space  between  the  floor  of  the  nares  and  the  inferior  turbinated 
bone,  is  seen  the  crest  of  attachment  for  this  scroll.  Still  higher, 
on  the  nasal  process,  are  the  crests  for  union  with  the  superior  and 
middle  scrolls.  The  middle  meatus,  into  which  opens  the  antrum, 
is  observed  to  be  quite  a  large  space,  particularly  when  compared 
with  the  superior  meatus,  which  is  the  slit  lying  between  the  upper 
and  middle  crests.     The  opening  of  the  antrum,  seen  in  the  back 


38  ORAL  DISEASES  AND  SURGERY. 

part  of  the- middle  meatus,  is  here  portrayed  of  a  natural  size — that 
is,  natural  to  the  disarticulated  bone.  It  will  be  remembered,  how- 
ever, that  it  is  filled  in  by  other  bones,  which,  in  the  articulated 
skull,  reduce  the  opening  to  an  outlet  not  larger  than  an  ordinary 
probe;  the  bones  closing  in  this  cavity  are  the  ethmoid,  palate,  and 
inferior  turbinated.     (See  descriptions  of  these  bones.) 

The  superior  maxillary  bone  articulates  with  nine  others:  by  its 
nasal  crest  with  the  frontal,  ethmoid,  lachrymal,  and  nasal ;  by  its 
malar  process  with  the  malar ;  at  the  intermaxillary  suture  with  the 
opposite  maxilla;  by  its  palatine  process  with  the  palate  and  vomer, 
and  at  the  lower  of  the  lateral  crests  with  the  inferior  turbinated  bone. 

Nine  muscles  have  their  origin  from  this  bone :  the  orbicularis 
palpebrarum,  the  inferior  oblique  of  orbit,  the  elevator  of  superior 
lip  and  wing  of  nose,  the  proper  elevator  of  lip,  the  angular  eleva- 
tor, the  compressor  naris,  the  depressor  of  the  ala,  the  masseter,  and 
the  buccinator. 

INFEKIOR  MAXILLAKY  BONE. 

The  inferior  maxillar}^  bone,  the  largest  and  strongest  bone  of  the 
face,  consists  of  a  body,  horseshoe  in  shape,  and  of  two  rami,  joined 
to  the  body  at  right  angles.  The  body,  which  is  the  anterior 
portion,  is  surmounted  by  a  process  of  more  or  less  spongy  bone, 
excavated  for  the  reception  of  the  teeth  ;  the  basement  portion,  or 


Fig.  4. — Inferior  Maxillary  Bonk. 


1,  body;  2,  ramus;  3,  symphysis;  4,  base;  5,  angle;  6,  mental  foramen;  7.  condyle;  8, 
coronoid  process ;  9,  semilunar  notch ;  10,  inferior  dental  foramen,  the  entrance  of  the 
corresponding  canal;  11,  alveolar  border;  12,  incisor  teeth;  13,  canine  tooth;  14,  pre- 
molars ;  15,  large  molars. 

that  portion  beneath  the  spongy  series  of  cells,  or  alveolar  process, 
is  made  up  of  very  dense  structure,  and  so  hard  and  resisting  as  to 
be  able  to  withstand  very  considerable  blows.  The  rami,  curved 
and   angular  at  the  base,  terminate  above  in  two   processes :   the 


ANATOMY  OF  THE  MOUTH  AND   FACE.  39 

condyloid,  for  articulation  with  the  glenoid  cavity  in  the  temporal 
bone,  and  the  coronoid,  for  the  attachment  of  the  temporal  muscle. 
The  angle  of  relation  of  the  perpendicular  to  the  horizontal  portion 
of  the  bone  varies  with  different  ages.  In  early  infancy  it  is  very 
obtuse ;  indeed,  the  two  portions  are  nearly  on  the  same  plane.  In 
adult  life  a  right-angled  relation  is  obtained,  and  this  changes  again 
to  the  obtuse  as  age  advances,  and  the  teeth  fall  out.  Taking 
advantage  of  a  knowledge  of  these  changes,  the  surgeon  is  enabled 
to  correct,  in  young  life,  the  great  deformity  of  an  unduly  projecting 
lower  jaw. 

Looking  at  the  external  face  of  the  body,  the  attention  is  first  at- 
tracted by  a  prominent  foramen  situated  beneath  the  bicuspid  teeth. 
This  foramen  is  called  the  mental,  and  from  it  pass  out,  to  be  dis- 
tributed to  the  lip  and  gum,  the  inferior  dental  artery  and  inferior 
dental  nerve;  the  situation  of  the  foramen  represents  the  line  of  re- 
lation between  the  hard  and  spongy  portions.  It  is  at  this  opening 
that  section  of  the  nerve  is  occasionally  made  for  severe  and  resisting 
labial  neuralgia.  A  bristle  passed  into  this  foramen,  inclined  back- 
ward, is  directed  along  a  canal  at  the  base  of  the  teeth,  and  emerges 
at  an  opening  situated  on  the  inner  face  of  the  ramus.  Passed  for- 
ward, it  enters  a  smaller  canal,  which  continues  under  the  central 
teeth,  carrying  to  these  organs  branches  of  the  nerve  and  artery. 
An  oblique  line — the  external  oblique  line,  as  it  is  called — fairly 
divides  the  surface  of  the  body  into  two  triangles.  This  line  is  for 
the  attachment  of  muscles,  and  accommodates  the  buccinator,  in 
part,  the  depressor  anguli  oris,  and  the  depressor  labii  inferioris  In 
old  persons,  after  the  loss  of  the  teeth,  and  absorption  of  the  alveolar 
process,  it  is  found  to  run  almost  along  the  upper  surface.  The 
centre  vertical  line,  called  the  symphysis,  represents  the  position  or 
division  existing  in  the  young  bone,  union  of  the  two  halves  not 
occurring  until  about  the  end  of  the  first  year.  The  levator  metiti 
muscle  has  its  origin  from  the  fossa  at  the  side  of  this  line.  The 
mental  process,  the  tubercle  at  the  base  of  the  symphysis,  is  only 
a  thickening,  for  the  greater  strength  of  the  part.  Viewed  from 
above  downward,  the  body  of  the  lower  jaw  is  concave ;  from  behind 
forward  it  is  convex. 

The  external  face  of  the  ramus  or  perpendicular  portion  of  the 
bone  exhibits  a  quadrilateral  aspect,  broken  above  by  a  notch,  the 
sigmoid,  which  separates  the  two  projecting  processes.  The  anterior 
of  these  processes  is  a  thin,  flattened,  triangular  eminence,  giving 
attachment  to  the  masseter  and  temporal  muscles.     The  posterior 


40  ORAL  DISEASES  AND  SURG  ERF. 

eminence,  the  condyloid  process,  is  an  oval  projection,  convex  and 
smooth,  with  its  face  covered  with  articular  cartilage,  and  having 
its  greatest  width  from  side  to  side.  This  process  articulates  the 
bone  with  the  temporal,  and  is  occasionally  the  seat  of  fracture  and 
luxation. 

The  internal  face  of  the  bone  presents  the  same  general  vievr  as 
the  external. 

A  ridge,  the  mylo-hyoid,  divides  the  body  by  its  oblique  line  into 
two  parts.  To  this  ridge  is  attached,  or  rather  from  it  has  origin,  a 
muscle  of  the  same  name.  This  muscle,  with  its  fellow  of  the  oppo- 
site side,  forms  the  floor  of  the  mouth,  so  that  looking  at  the  line  one 
sees  exactly  how  much  of  the  bone  is  within  and  how  much  without 
the  oral  cavity.  Just  below  the  line,  about  midway  of  the  body  of 
the  bone,  is  seen  a  fossa  or  depression,  the  submaxillary,  for  the 
accommodation  of  the  gland  of  that  name.  The  mesial  line  or  sym- 
physis presents  on  either  side  two  tubercles,  called  the  genial 
tubercles,  to  which  are  attached  the  genio-hyoglossi  and  the  genio- 
hyoideus  muscles.  Outside  of  these  tubercles;  on  either  side,  are 
two  fossae  for  the  lodgment  of  the  sublingual  glands  ;  these  fossae 
are  called  by  the  name  of  the  glands.  It  will  be  observed  that  as 
these  fossae  lie  above  the  ridge,  the  lingual  glands  must  be  within 
the  mouth,  while  the  submaxillary  fossae  being  below  it,  these  glands 
are  without  the  cavity.  One  most  important  feature  to  remark  is 
the  relation  of  the  anterior  border  of  the  vertical  portion  of  the  bone 
to  the  molar  teeth.  It  not  unfrequently  happens  that  this  border  so 
nearly  approximates  the  second  molar  that  there  is  no  room  for  the 
eruption  of  the  third;  the  most  formidable  inflammations  sometimes 
result  from  such  a  cause,  the  crown  of  the  tooth  being  held  down 
under  the  ramus.  Extraction  of  the  adjoining  anterior  tooth,  it  will 
be  seen,  would  allow  the  confined  one  to  fall  forward. 

A  marked  feature  of  diflFerence  between  the  internal  and  external 
face  of  the  ramus  is  the  existence  in  the  former  of  a  large  foramen, 
the  inferior  dental,  for  transmission  into  the  canal  alluded  to,  as 
passing  beneath  the  teeth,  of  the  inferior  maxillary  vessels  and 
nerve.  The  position  of  this  foramen  is  to  be  appreciated  by  accu- 
rate measurement,  as  just  within  it  is  performed  the  operation  of 
section  of  the  nerve.  A  groove,  the  raylo-hyoid,  transmits  to  the 
muscle  of  the  ridge  an  artery,  which  comes  from  the  inferior  maxil- 
lary just  as  it  is  about  to  enter  its  canal.  Attached  to  the  border 
and  internal  face  of  the  coronoid  process  is  the  tendinous  expansion 
of  the  temporal  muscle,  while  to  the  face  of  the  condyloid  is  attached 


ANATOMY  OF  THE  MOUTH  AND   FACE. 


41 


the  pteiygoideus  externus,  the  internal  pterygoid  being  related  to 
the  angle.  The  semilunar  depression,  separating  the  two  condyles, 
the  sigmoid  notch,  is  crossed  by  the  masseteric  artery  and  nerve, 
while  in  its  immediate  proximity  are  the  internal  carotid  and  internal 
maxillary  arteries. 

Figs.  5  and  6. — Palate  Bone. 


Posterior  view  of  the  right  palate  boxe. 
1,  palate  plate;  2,  nasal  plate;  3,  pyraiiiiditl 
process  ;  4,  articular  border  for  the  left  palate 
lione ;  5,  palate  spine ;  6,  ridge  for  junction 
with  the  turbinated  bone;  7, spheno-palatine 
notch,  between  8,  the  orbital,  and  9,  the 
sphenoidal  process ;  10,  groove  for  the  in- 
ternal pterygoid  process  of  the  sphenoid 
bone ;  11,  position  of  the  posterior  palatine 
foramen. 


Exterior  view  op  the  right  palate  bone. 
1,  rough  surface  articulating  with  the  su- 
perior maxillary  bone,  and  diminishing  the 
aperture  of  the  maxillary  sinus;  2,  posterior 
palatine  canal,  completed  by  the  tuberosity 
of  the  superior  maxillary  bone;  3,  spheno- 
palatine notch ;  4,  5,  6,  orbital  process ;  4, 
surface  directed  toward  the  pterygo-max- 
illary  fossa;  5,  orbital  surface;  6,  maxillary 
border;  7,  sphenoidal  process;  8,  pyramidal 
process. 


The  palate  bone  in  position  is  seen  to  form  the  back  part  of  the 
hard  palate,  a  portion  of  the  floor  and  side  of  the  nares,  and  a  part 
of  the  orbital  cavity.  It  also  enters  into  the  formation  of  three 
fossae:  the  zygomatic,  spheno-maxillary,  and  pterygoid.  Like  the 
inferior  maxillary,  the  bone  consists  of  two  portions :  one  horizontal, 
the  other  at  right  angles  with  it,  or  vertical.  The  horizontal  portion 
is  irregularly  quadrilateral,  presenting  two  surfaces  and  four  borders  : 
the  upper  of  the  two  surfaces  is  concave,  and  forms  the  back  part  of 
the  floor  of  the  nares;  the  lower  or  under  surface  is  also  concave,  and 
forms  the  back  of  the  hard  palate.  The  suture  of  connection  with 
the  maxillary  bone  is  always  plainly  seen,  and  is  called  the  palato- 
maxillary suture. 

In  glancing  at  the  bone  from  its  posterior  view,  it  is  seen  very 
markedly  to  resemble  the  letter  L.  Studying  it  in  detail,  we  may  re- 
mark, first,  the  spine,  situated  at  the  base  of  the  interpalatal  suture, 
and  which  gives  attachment  to  one  of  the  motores  uvulae  muscles; 
passing  toward  the  vertical  portion,  the  concave  character  of  both 


42  ORAL   DISEASES  AND   SURGERY. 

nasal  and  palatine  faces  is  observed,  the  former  much  more  marked 
than  the  latter.  This  nasal  concavity  is  seen  to  end  at  a  crest  or 
ridge  on  the  vertical  portion.  This  ridge  is  the  most  posterior  articular 
surface  of  the  inferior  turbinated  bone,  and  the  space  below  it  is  a  part 
of  the  inferior  meatus.  The  base  of  the  vertical  portion  is  pyramidal, 
and  ends  in  a  process  called  the  pterygoid  or  tuberosity,  its  articu- 
lation being  with  the  pterygoid  plates  of  the  sphenoid.  At  the 
back  part  of  this  process  are  seen  three  grooves :  the  middle  one, 
wide  and  smooth,  forms  part  of  the  pterygoid  fossa,  and  gives 
attachment  to  the  internal  pterygoid  muscle ;  the  two  lateral  are 
rough  and  uneven,  and  articulate  with  the  anterior  border  of  each 
pterygoid  plate. 

Passing  upward,  the  prominent  feature  is  the  sphenoid  process. 
This  is  a  comparatively  thin  plate,  made  up  of  an  articular  and  non- 
articular  surface,  a  groove  and  a  notch.  The  articular  surface  as- 
sociates the  plate  with  the  sphenoid  bone ;  the  non-articular  enters  into 
the  composition  of  the  zygomatic  fossa.  The  groove  contributes  to 
the  formation  of  the  pterygo-palatine  canal ;  and  the  notch,  closed 
in  above  by  the  orbital  process,  forms  the  greater  part  of  the 
spheno-palatine  foramen.  This  process  also  contributes,  by  one  of 
its  surfaces,  to  the  lateral  wall  of  the  nasal  fossa. 

The  orbital  process,  resting  on  the  sphenoidal,  is  composed  of  five 
plates,  or  surfaces,  and  includes  a  cavity.  Of  these  processes,  three 
are  articular,  two,  free  surfaces.  The  articular  are  the  maxillary, 
the  sphenoidal,  and  the  ethmoidal,  associating  the  process  with  these 
bones.  The  free  surfaces  are  the  orbital,  forming  a  small  part  of  the 
orbital  cavity,  and  the  zygomatic,  entering  into  the  composition  of 
the  zygomatic  fossa. 

Looking  on  the  inner  face  of  the  bone,  we  remark,  first,  the  articu- 
lar process.  This  process  or  surface  associates  the  bone  with  its 
fellow  of  the  opposite  side;  above,  it  forms,  with  its  neighboring 
piece,  a  ridge  receiving  the  vomer.  The  body  of  this  face  seems 
made  up  of  two  great  concavities,  with  a  separating  ridge.  This 
ridge  articulates  the  inferior  turbinated  bone ;  the  concavity  above 
is  part  of  the  middle  meatus ;  that  below,  part  of  the  inferior 
meatus;  the  ridge  or  crest  is  called  the  inferior  turbinated  crest. 
A  second  crest,  situated  at  the  upper  boundary  of  the  middle  meatus, 
articulates  the  lower  scroll  of  the  ethmoid,  or  the  middle  turbinated 
bone.  This  is  called  the  superior  turbinated  crest.  Just  below  it  is 
seen  the  now  perfected  notch  in  the  sphenoidal  process,  the  spheno- 
palatine foramen,  for  the  transmission  of  the  vessels  and  nerve  of 


ANAT03IY  OF  THE  MOUTH  AND  FACE.  43 

that  name.  Abov^e  the  superior  crest  is  seen  the  posterior  part 
of  the  superior  meatus,  a  horizontal  groove,  bounded  above  by  the 
lower  border  of  the  ethmoidal  face  of  the  orbital  process. 

The  orbital  process,  seen  from  this  side,  presents  three  surfaces  : 
the  maxillary  in  front,  the  orbital  above,  and  the  ethmoidal  in- 
ternally. 

The  lateral  surfaces  of  the  bone  are  almost  entirely  articular. 
That  looking  front  associates  in  its  full  length  with  the  superior 
maxillary  bone ;  that  looking  back,  with  the  sphenoid,  through  its 
pterygoid  processes.  This  very  full  articulation  with  these  two 
bones  leads  us  to  speak  of  the  palate  bone  as  being  wedged  between 
them,  and  being  supported  by  them. 

The  articulations  of  the  palate  bone  are  with  seven  others :  the 
superior  maxillary,  the  inferior  and  superior  turbinated,  the  vomer, 
the  sphenoid,  the  ethmoid,  and  its  fellow  of  the  opposite  side. 

The  muscles  attached  to  it  are  the  tensor  palati,  the  motor  uvulae, 
and  the  internal  and  external  pterygoid. 

THE  VOMER. 

The  vomer,  plowshare-shaped,  constitutes  a  portion  of  the  septum 
narium.  It  articulates  below  with  the  interpalatine  suture  of  the 
superior  maxillae  and  palate  bones  ;  above,  with  the  perpendicular 
plate  of  the  ethmoid ;  by  its  base  with  the  laminae  and  rostrum  of 

Fig.  7. — The  Vomer. 


View  of  left  side.  1, 1,  broad  groove  receiving  the  rostrum  of  the  sphenoid  bone ; 
2,  2,  inferior  border  articiihiting  with  the  palate  plates  of  the  superior  maxillary  and 
palate  bones ;  3,  posterior  border,  the  dividing  line  of  the  posterior  nares  ;  4,  4,  groove 
border  receiving  a  narrow  slip  of  cartilage,  situated  between  the  vomer  and  the  nasal 
plate  of  the  ethmoid  bone ;  5,  5,  border  for  the  cartilaginous  septum  of  the  nose ;  6,  6, 
nasal  surface. 

the  sphenoid  bone ;  in  front  it  associates  with  the  triangular  cartilage ; 
posteriorly  it  is  seen  separating  the  nares.  The  naso-palatine  groove, 
seen  running  from  the  base,  forward  and  downward,  toward  the 
triangular  cartilage,  transmits  the  naso-palatine  nerve  to  the  inter- 
palatine canal. 


44 


ORAL  DISEASES  AND  SURGERY. 


Occasionally  it  is  the  case  that  the  vomer  is  found  markedly  bent 
to  one  side  or  the  other,  and  this  to  such  an  extent,  frequently,  as 
completely  to  obliterate  one  of  the  nares,  requiring  an  operation  for 
its  relief.  The  vomer  is  also  subject  to  syphilitic  attacks,  and  fre- 
quently breaks  down,  allowing  the  arch  of  the  nose  to  fall  in. 


FiQ.  8. — Articular  Kelations  of  Vomer. 


Vertical  section  of  the  face,  exhibiting  the  osseous  nasal  septum.  1,  frontal  bone; 
2,  frontal  sinus;  3,  nasal  spine  of  the  frontal  bone;  4,  nasal  bone;  5,  nasal  spine  of  the 
superior  maxillary  bone  ;  6,  nasal  process  of  the  same  bone  ;  7,  border  of  the  palate  plate 
of  the  same;  8,  incisive  foramen;  9,  left  posterior  naris ;  10,  palate  plate  of  the  palate 
bone ;  11,  nasal  plate  of  the  ethmoid  bone ;  12,  ethmoidal  crest ;  13,  vomer ;  14,  left  turbi- 
nated bone;  15,  sphenoidal  sinus;  16,  internal  pterygoid  process;  17,  external  pterj'goid 
process. 

The  articulation  is  seen  to  be  with  six  bones ;  the  two  superior 
maxillary,  the  two  palate,  the  sphenoid,  and  the  ethmoid  ;  also  with 
the  cartilaginous  septum,  not  shown  in  the  view,  but  occupying  the 
triangular  break. 

Running  across  each  lateral  face  of  the  nasal  cavities  are  three 
scrolls,  known  as  the  turbinated  bones.  Of  these  scrolls,  the  two 
upper  are  simply  processes,  or  portions  of  the  ethmoid  bone;  the 
lower  is  a  distinct  piece,  and  is  called  the  inferior  turbinated  bone. 

Observing  the  position  of  these  scrolls,  it  is  remarked  that  each 
curves  over  a  portion  of  the  sides  of  the  nares.  The  spaces  thus 
inclosed  are  called  the  meatus.  The  lower  or  inferior  of  these 
cavities  is  bounded  below  by  the  floor  of  the  nares ;  above  by  the 
inferior  turbinated  bone.     An  opening  seen  about  its  middle  is  the 


ANATOMY  OF  THE  MOUTH  AND   FACE. 


45 


outlet  of  the  lachrymal  canal.  The  middle  meatus  is  the  space 
bounded  below  by  the  upper  surface  of  the  inferior  scroll ;  above  by 
the  lower  surface  of  the  middle  scroll.    A  foramen  seen  in  this  meatus 

Fig.  9. — Position  and  Eelations  or  Turbinated  Bones. 


A'lEW  OF  THE  OUTER  WALL  OF  THE  RIGHT  NASAL  FOSSA.  1,  froiitiil  bone  ;  2,  its  orbital  plate ; 
3,  its  n.asal  spine;  4,  nasal  bone;  5,  etl)nioidbone;  6,  its  upper  turbinated  process;  7,  its 
lower  turbinated  process;  8,  turbinated  bone;  9,  process  of  the  lachrymal  bone  within 
the  position  of  which  is  the  lachrymo-naeal  duct ;  10,  nasal  spine  of  the  superior  maxil- 
lary bone;  11,  naso-palatine  canal ;  12,  palate  plate  of  the  superior  maxillary  bone;  13, 
nasal  process  of  the  latter;  14,  external  pterygoid  process;  15,  internal  pterygoid  pro- 
cess ;  16,  nasal  plate  of  the  palate  bone;  17,  its  palate  plate ;  18,  posterior  palatine  fora- 
men ;  19,  superior  meatus  of  the  nose  ;  20,  middle  meatus  ;  21,  inferior  meatus  ;  22,  frontal 
sinus  ;  23,  sphenoidal  sinus  ;  24,  its  communication  with  the  upper  back  part  of  the  nose; 
25,  spheno-palatine  foramen ;  26,  orifice  of  the  maxillary  sinus. 


is  the  outlet  of  the  antrum.     The  superior  meatus  is  the  slit  seen 
between  the  two  upper  scrolls. 

The  distinct,  or  inferior  turbinated  bone,  is  a  thin,  spongy  scroll, 
having  a  base  of  attachment  the  whole  length  of  the  lower  crest 
seen  on  the  nasal  surfaces  of  the  maxillary  and  palate  bones ;  the 
opposite,  or  inferior  edge,  is  free,  and  lies  in  the  middle  of  the  in- 
ferior meatus.  Viewed  from  its  inner  surface,  the  bone  presents  a 
most  irregular  appearance,  being  perforated  with  numerous  aper- 
tures, sulci,  and  grooves,  for  the  accommodation  of  arteries  and  veins. 
Two  processes,  the  lachrymal  and  the  ethmoid,  are  seen  to  break  the 
regularity  of  the  upper  convexity.  The  anterior — the  lachrymal — 
articulates  with  the  inferior  angle  of  the  lachrymal  bone,  and  with 
the  nasal  crest  of  the  maxillary  bone,  thus  assisting  in  forming  the 


46 


ORAL  DISEASES  AND  SURGERY. 


lachrymal  canal.  The  posterior — the  ethmoidal — articulates  with  the 
descending  unciform  process  of  the  ethmoid  bone.  Turning  here  the 
bone,  we  see  a  third  process,  or  division,  as  it  were,  made  in  the 
ethmoidal.  This  process  is  called  the  maxillary.  It  curves  down- 
ward within  the  inferior  meatus,  assisting  in  filling  up  the  antral 
orifice,  and,  in  its  attachment,  steadies  the  bone  firmly  on  the  side 
of  the  nares.  Externally,  the  general  appearance  of  the  bone  is  con- 
cave; internally,  or  looking  toward  the  septum  narium,  it  is  convex. 
If  the  external  surface  were  convex,  and  the  processes  absent,  the  bone 
might  very  well  be  likened  in  shape  to  the  Indian  stone  arrow-head. 

The  turbinated  bone  is  very  subject  to  specific  inflammation,  and 
which,  without  great  care,  is  apt  to  end  in  its  death. 

The  bone  articulates  with  four  others  :  the  ethmoid,  the  lachry- 
mal, the  maxillary,  and  the  palate.     No  muscles  are  attached  to  it. 

THE  ETHMOID  BONE. 


Fig.  10. — Ethmoid  Bone- 
View. 


-Gexeral 


A  horizontal  cribriform  plate  of  bone,  with  a  crest  along  its  middle; 

a  perpendicular  plate  dropping  down  from  the  centre  of  this  first 

piece;  two  little  oblong  square 
boxes,  hung  on  either  side  of  the 
per[)endicular  plate,  leaving  the 
space  of  a  narrow  slit  between 
the  boxes  on  either  side  and  the 
plate,  and  we  have  the  complete 
idea  of  the  ethmoid  bone.  Look- 
ing at  the  bone  from  above,  we  re- 
mark, first,  the  crest — crista  galli 
it  is  called — giving  attaciimeut  to 
the  falx  cerebri.  On  either  side 
of  this  crest  is  seen  a  depression 
perforated  with  a  number  of  fora- 
mina. These  depressions  lodge 
the  olfactory  bulbs,  and  the  fora- 
mina transmit  to  the  nose  the 
olfactory  filaments,  the  three  sets 
having  corresponding  foramina. 
A  slit  seen  at  the  side  of  the 
crista  galli  transmits  the  nasal 
branch  of  the  ophthalmic  nerve. 

Looked  at  anteriorly,  the  crest  is  seen  to  terminate  in  two  little 


1,  orbital  surface  of  the  lateral  mass  ;  2 
posterior  extremity  of  the  cribriform  plate, 
Avhich  unites  the  lateral  masses,  and  is  de- 
pressed and  perforated  with  numerous  fora- 
mina on  each  side  of  the  ethmoidal  crest  3; 
the  two  oblique  processes  in  advauce  of  the 
latter  are  the  ethmoidal  wings;  4,  anterior 
extremity  of  the  nasal  plate;  5,  the  ethmoidal 
sinuses. 


ANATOMY  OF   THE  310 UTH  AND   FACE.  47 

horns  or  wings;  these  articulate  with  depressions  in  the  os  frontis, 
and  occasionally  in  a  manner  so  imperfect  as  to  leave  an  opening 
or  foramen.  When  existing,  this  foramen  accommodates  a  nasal 
vein,  which  passes  upward,  to  terminate  in  the  longitudinal  sinus ; 
the  rupture  of  this  vein,  discharging  the  sinus,  has  saved  many 
lives  in  attacks  of  congestion. 

The  perpendicular  plate,  exhibited  by  the  removal  of  one  of  the 
lateral  masses,  is  simply  a  thin  plate  of  bone.  This,  descending  in 
the  middle  line  of  the  nose,  assists  the  vomer  in  separating  this 
cavity  into  two  lateral  halves.  In  front,  it  is  received  into  the 
groove  between  the  two  nasal  bones ;  below,  it  looks  downward  and 
forward,  and  receives  the  triangular  cartilage  ;  back  of  this  it  articu- 
lates with  the  vomer,  and  still  farther  back  with  the  sphenoid. 

On  each  side  of  the  plate  are  seen  numerous  grooves  leading  from 
the  foramina  in  the  horizontal  or  cribriform  plate;  these  are  chan- 
nels receiving  and  shielding  the  inner  olfactory  filaments. 

The  boxes  or  lateral  masses  are  very  loose,  and  areolar-like,  and 
constitute  a  series  of  cells.  Disarticulated,  many  of  these  cells 
appear  broken  ;  but  when  associated  with  the  ethmoidal  fissure  of  the 
frontal  bone,  with  the  sphenoidal  scrolls,  with  the  orbital  processes 
of  the  palate  bones,  and  the  nasal  processes  of  the  maxillary  and 
palate  bones,  the  cells  are  found  to  be  completed.  The  union  of 
these  cells,  more  or  less  directly,  with  the  common  uares,  and  the 
fact  that  they  are  all  lined  by  a  mucous  membrane  continued  from 
these  fossae,  explain  the  sense  of  congestion  and  fullness  known  as 
"  cold  in  the  head." 

The  outer  surface,  or  face  of  the  boxes,  looks  very  much  in  color 
like  the  common  clarified  quill,  is  semi-translucent,  square  in  shape, 
and  very  smooth.  Referring  to  the  view  of  the  skull  (Fig.  1),  this 
surface  will  be  seen  entering  into  the  composition  of  the  orbital 
cavity. 

The  portion  of  the  ethmoid  which  receives  and  articulates  the 
process  passing  upward  from  the  inferior  turbinated  bone  is  a 
hook-like  projection  from  the  under  surface  of  these  lateral  masses. 
It  is  called  the  unciform  process,  and  assists  in  narrowing  the  orifice 
of  the  antrum  and  supporting  the  masses. 

The  internal  surface  of  each  lateral  mass  approaches  the  perpen- 
dicular plate.  At  the  upper  part  is  the  narrow  fissure,  bounded  by 
a  scroll-like  process  on  the  surface,  known  as  the  superior  meatus. 
The  scroll  has  received  the  name  of  the  superior  turbinated  bone. 
Below  this  first  scroll,  on  the  same  surface,  is  a  second.     This  second 


48 


ORAL   DISEASES  AND   SURGERY. 


scroll  is  called  the  middle  turbinated  bone,  and  the  space  below  it, 
between  it  and  the  inferior  turbinated  bone,  is  the  middle  meatus. 

In  looking  at  the  ethmoid  bone  in  position,  it  will  be  seen  to  be 
wedged  in  between  the  nasal,  frontal,  lachrymal,  and  maxillary- 
bones  in  front,  and  the  sphenoid  behind;  below,  it  is  supported  by 
the  turbinated,  vomer,  and  palate  bones.  Blows  received  upon  the 
bridge  of  the  nose  have  not  unfrequently  carried  the  crista  galli  into 
the  substance  of  the  brain  ;  while  maxillary  diseases  find  an  easy 
road  to  the  base  of  the  cranium  through  the  nasal  communication 
with  the  ethmoidal  cells. 

THE    SPHENOID   BONE. 

The  sphenoid  bone,  named  from  its  wedge-like  relations  to  other 
bones  of  the  cranium,  has  been  frequently  and  most  aptly  compared 
in  appearance  to  a  "bat"  with  extended  wings  and  unflexed  legs. 

Fig.  11. — The  Sphenoid  Bone — Upper  View. 


1.  pituitary  fossa;  2,  olivary  process;  3,  declivity;  4,  anterior  clinoid  process;  5,  pos- 
terior clinoid  process  ;  6,  posterior  border  of  the  body  ;  7,  cerebral  surface  cff  the  great 
wing;  8,  articular  surface  for  the  frontal  bone;  9,  articular  border  for  the  temporal  bone; 
10,  spinous  process;  11,  small  wing;  12,  liorder  articulating  with  the  orbital  plate  of  the 
frontal  boue;  13,  border  joining  the  ethmoid  bone;  14,  optic  foramen;  15,  sphenoidal  for- 
amen; 16,  rotund  foramen;  17,  oval  foramen;  18,  spinous  foramen;  19,  groove  for  the 
internal  carotid  artery. 


In  looking  at  the  disarticulated  bone,  we  first  observe  a  central 
portion  or  body;  this  body  is  irregularly  square,  and  marked  on  all 
its  surfaces  with  features  which  one  at  once  infers  to  be  possessed 
of  anatomical  significance.  Extending  laterally  on  either  side  from 
the  body  are  two  great  wings ;  these  wings  are  made  double  by  a 
lacerated  foramen,  and  instead  of  being  spoken  of  and  described  as 
a  single  pair,  are  mostly  viewed  as  two  pairs, — the  larger  portion 
being  called  the  greater  wings,  the  smaller  pair  the  lesser  wings. 


ANATOMY  OF   THE  310 UTH  AND   FACE. 


49 


The  leg's,  falling  from  the  base  of  the  cranium,  are  found  separated 
by  a  notch  into  two  portions, — this  separation,  however,  being  much 
more  marked  behind  than  in  front:  they  have  received  the  name  of 
pterygoid  processes. 

Fig   12. — The  Sphenoid  Bone — Front  View. 


1,  2,  sphenoidal  crest  and  rostrum  for  joining  the  nasal  plate  of  the  ethmoid  hone  and 
the  vomer;  3,  entrance  of  the  sphenoidal  sinuses;  4,  small  wing;  5,  optic  foramen 
piercing  its  base;  6,  sphenoidal  foramen;  7,  rotund  foramen;  8,  orbital  surface  of  the 
great  wing;  9,  temporal  surface  of  the  same;  10,  ridge  separating  the  temporal  and 
spheno-maxillary  fossse;  11,  position  of  the  i)terygo-palatine  canal ;  12,  pterygoid  canal ; 
13,  internal  pterygoid  process,  ending  in  a  hook;  14,  15,  external  pterygoid  process  ;  16, 
spinous  process ;  17,  oval  foramen ;  18,  spinous  foramen. 

Beginning  a  study  of  the  body  from  its  superior  or  cranial  sur- 
face, attention  is  first  naturally  directed  to  a  saddle- like  depression 
occupying  a  large  portion  of  this  face.  This  depression  lodges  a 
little  body  attached  to  the  floor  of  the  third  ventricle,  the  pituitary 
body  ;  hence  it  is  called  by  many  authors  the  pituitary  depression 
or  fossa;  and  from  its  resemblance  to  the  Turkish  saddle  it  is 
as  frequently  named  the  sella  turcica,  A  number  of  little  pits 
seen  on  the  floor  are  foramina  transmitting  vessels  of  nutrition. 
On  either  side  are  two  processes  ;  these  correspond  to  two  others, 
terminating  the  plate  of  bone  which  represents  the  back  of  the 
saddle.  The  four  have  been  compared  to  the  posts  of  a  bedstead, 
and  are  called  clinoid  processes.  Passing  forward,  an  olive-shaped 
eminence  is  next  noticed, — the  olivary  process;  and  directly  in  front 
of  this,  a  groove  or  oblong  fossa.  This  groove  has  resting  in  it  the 
commissure  of  the  optic  nerve,  and  hence  is  called  the  optic  groove. 
Passing  directly  forward,  we  find  the  surface  terminate  in  a  spine  or 
projecting  point;  this  point  articulates  the  surface  with  the  eth- 
moidal bone,  and  is  called  the  ethmoidal  spine  ;  between  this  spine 
and  the  optic  groove  is  a  slight  eminence  falling  off  on  either  side 
into  a  line  of  depression  ;  these  lines  lodge  the  olfactory  nerves. 
Two  foramina,  seen  on  this  surface  at  either  terminus  of  the  optic 


50  OBAL  DISEASES  AND   SURGERY. 

groove,  are  called  optic  foramina;  they  transmit  to  the  orbital  cavi- 
ties the  optic  nerves  and  ophthalmic  arteries.  From  the  back  of  the 
saddle  the  surface  is  seen  to  slope  gradually  downward  ;  this  con- 
cave plane  lodges  the  medulla  oblongata,  and  terminates  at  the  line 
of  union  with  the  occipital  bone.  On  either  side  is  situated  a  tor- 
tuous depression,  in  which  lie  the  internal  carotid  artery  and  the 
cavernous  sinus. 

Turning  now  to  the  anterior  surface,  we  observe,  first,  a  rostrum 
or  beak,  for  articulation  with  the  perpendicular  plate'of  the  ethmoid. 
On  either  side  of  this  beak  are  seen  scrolls  of  bone,  or  rather  lamellae, 
— the  sphenoidal  turbinated  bones,  as  they  are  called.  These  la- 
melliB,  we  find,  imperfectly  close  sinuses  which  hollow  out  the  sub- 
stance of  the  body,  and  which,  in  articulation,  are  found  to  commu- 
nicate with  the  upper  part  of  the  nose,  and  frequently  with  the 
ethmoidal  cells ;  being  lined  with  the  mucous  membrane  of  the 
nares,  and  subjected  consequently  to  the  sympathies  of  continuity. 

The  inferior  surface  presents  us,  first,  with  the  rostrum  or  beak; 
continued  from  the  anterior  face,  this  spine  is  received  into  a  groove 
or  fissure  in  the  vomer.  On  either  side  are  laminae  of  bone,  which 
pass  to  the  pterygoid  processes ;  these  plates  or  laminae  are  called 
vaginal  processes.  Close  to  the  pterygoid  process  is  seen  a  groove, 
which  the  sphenoidal  process  of  the  palate-bone  converts  into  a 
canal ;  this  groove  transmits  the  pterygo-palatine  vessels  and  pha- 
ryngeal nerve. 

The  posterior  surface  in  this  bone  exhibits  simply  a  quadrilateral 
sawed  surface,  a  union  existing  with  the  occipital  at  this  point, 
which  has  required  the  saw  for  its  separation.  Hence  it  has  been 
a  common  practice  with  many  writers  to  consider  the  sphenoid  and 
occipital  as  one  bone,  and  to  refer  to  them  as  the  spheno-occipital  bone. 

The  Wings,  which  may  next  claim  attention,  are  called  the  greater 
and  lesser,  the  separation  existing  at  the  lacerated  foramen.  The 
greater  wings  extend  laterally,  and  assist  largely  in  forming  the 
floor  of  the  fossae  which  receive  the  middle  lobes  of  the  brain. 
Looked  at  from  the  encranial  aspect,  attention  is  first  attracted  to 
six  foramina, — three  on  either  side.  The  first  of  these  is  a  round 
hole,  and  is  called  the  foramen  rotundum  ;  it  transmits  from  the 
brain  to  the  superior  maxillary  bone  the  second  branch  of  the  fifth 
nerve.  The  second  hole  is  oval  in  shape  ;  hence  called  the  foramen 
ovale :  it  transmits  the  third,  or  inferior  maxillary  branch  of  the 
fifth.  The  third,  the  foramen  spinosum,  transmits  the  middle  me- 
ningeal artery.     A  fourth  foramen  is  occasionally  found  in  the  great 


A.VATOMY  OF   THE  MOUTH  AND   FACE.  51 

wing, — the  vesalii.  When  existing,  it  is  occupied  by  a  small  vein. 
The  general  floor  of  these  wings  is  concave,  and  marked  with  eleva- 
tions and  depressions  for  the  accommodation  of  neighboring  convo- 
lutions. 

Turning  the  bone,  these  wings  are  seen  to  be  made  up  of  three 
surfaces:  the  encranial  face,  as  just  described;  an  external  surface, 
occuj)ying,  when  in  articulation,  a  place  in  the  base  of  the  skull ;  and 
an  orbital  surface. 

The  external  surface  is  irregularly  convex,  and  is  separated  into  two 
portions  by  a  ridge  called  the  pterygoid.  The  superior  of  these  two 
faces  is  seen  entering  into  the  composition  of  the  temporal  fossa  for 
lodgment  of  the  temporal  muscle.  The  inferior  face  lies  beneath  the 
zygoma,  and  forms  part  of  the  fossa  of  this  name,  giving  attachment 
to  the  external  pterygoid  muscle.  Running  from  the  postero-lateral 
angle  of  the  surface  is  seen  a  prolonged  spine :  to  this  are  attached 
the  laxator  tympani  muscle  and  the  internal  lateral  ligament  of  the 
lower  jaw. 

•  The  orbital  face  of  the  wing  assists  in  forming  the  outer  boundary 
of  the  orbit ;  it  is  quadrilateral  in  form,  smooth,  and  concave.  Below, 
it  has  a  somewhat  rounded  border,  and  enters  into  the  formation  of 
the  spheno-maxillary  fissure;  internally,  it  assists  in  forming  the 
sphenoidal  fissure.  At  the  lower  edge  of  the  inner  border  is  a  deli- 
cate spine,  giving  origin  to  one  head  of  the  external  rectus  muscle. 
The  foramina  generally  seen  on  this  face  are  called  orbitar  foramina  : 
they  transmit  small  arteries. 

The  lesser  wings,  frequently  described  as  the  processes  of  In- 
grassias,  are  seen  on  the  encranial  surface  extending  outward,  over- 
lying at  their  apices  the  great  wings.  These  wings  are  triangular 
in  shape,  having  their  bases  associated  with  the  body  of  the  bone. 
In  articulation  they  complete  the  posterior  boundary  of  the  anterior 
fossae  of  the  cranium,  and  are  lodged  in  the  fissure  of  Sylvius.  The 
fissure  or  slit  which  separates  them  from  the  great  wings  is  called 
the  lacerated  foramen.  It  transmits  the  first  or  ophthalmic  branch 
of  the  fifth  nerve,  the  third,  fourth,  and  sixth  nerves,  and  the  oph- 
thalmic vein  The  lesser  wings  are  connected  with  the  body  by  two 
footstalks,  inclosing  within  them  and  assisting  in  forming  the  optic 
foramina.  A  process  seen  jutting  backward  from  the  foramen  is 
called  the  anterior  clinoid  process  ;  to  it  is  attached  the  common 
tendon  of  the  recti  muscles. 

The  legs  or  pterygoid  processes,  seen  falling  from  the  point  of 
union  of  the  great  wings  with  the  body,  consist  of  two  plates,  sep. 


52 


ORAL  DISEASES  AND   SURGERY 


arated  beliind  by  a  deep  notch,  but  united  almost  fully  in  front.  The 
external  plate  is  broad  and  curved,  and  forms  part  of  the  zygomatic 
fossa  ;  to  it  is  attached  the  external  pterygoid  muscle.  The  internal 
face  forms  part  of  the  pterygoid  fossa,  and  gives  origin  to  the  inter- 
nal pterygoid.  The  internal  plate  has  a  particular  interest ;  it  ends 
in  a  tubercle  or  hook-like  process,  which  is  felt  in  the  mouth  just 
back  of  the  maxillary  tuberosity, — the  hamular  process;  around  it 
turns  the  tendon  of  the  tensor  palati  muscle, — a  tendon  to  be  divided 
in  the  operation  for  cleft  palate.  The  base  of  this  internal  plate  forms 
a  fossa,  the  scaphoid,  from  which  originates  the  tensor  muscle  just 
alluded  to.  The  outer  surface  of  this  plate  forms  the  pterygoid 
fossa;  the  inner  assists  in  forming  the  outer  posterior  boundary  of 
the  nares. 

The  base  of  the  pterygoid  process  is  quite  broad,  and  in  front  gives 
support  to  Meckel's  ganglion.     The  vidian  canal  jjasses  througli  it. 

The  sphenoid  articulates  with  all  the  bones  of  the  cranium,  witii 
the  two  malar,  the  vomer,  and  two  palate  bones  of  the  face. 

The  muscles  to  which  it  gives  origin  are  the  temporal,  external, 
and  internal  pterygoid,  tensor  palati,  laxator  tympani,  levator  pal- 
pebrae,  the  recti  of  the  eye,  and  superior  oblique  of  eye. 

THE  NASAL  BONE. 


The  figure  exhibits  the  faces  of  a  left  nasal   bone  articulating 

with  its  fellow,  which  is  its  counterpart;  the  two  occupy  the  quadri- 

^      ,„      „  lateral  space  existing  between  the  two  maxillarv 

Fig.  13  —Nasal  '  * 


Bone. 


bones  and  the  frontal,  and  form  the  prominence 
known  as  the  nasal  bridge.  That  these  bones  vary 
considerably  in  shape  would  be  inferred  from  va- 
riations in  the  shape  of  the  bridge  so  frequently 
seen.  Looked  at  from  above  downward,  each 
bone  is  observed  to  be  concave,  while  viewed 
from  side  to  side,  it  is  convex;  several  light 
grooves  are  commonly  noticed  on  the  surface 
for  the  accommodation  of  vessels  ;  the  foramen 
seen  about  the  centre  transmits  a  small  vein. 

The  inner  surface   reverses    relations  with  the 
outer — being  convex  from  above    below,  concave 
from  side  to  side.     Its  onh^  feature  of  interest  is 
a  groove  for  the  lodgment  of  the  nasal  nerve. 
The  borders  of  the  bone  are  three  articular  and  one  free.     The 


Anterior  view  or 

THE  LEFT  XASAL  BOXE. 

1,  frontal  border  ;  2, 
nasiU  border;  3, niiixil- 
lary  border  ;  4,  lower 
border  ;  5,  nasal  fora- 
men. 


ANATOMY  OF   THE  MOUTH  AND   FACE. 


53 


superior,  serrated  and  somewhat  narrow,  fits'  in  the  frontal  notch, 
forming  the  fronto-nasal  articulation.  The  lateral  border  is  bev- 
eled, at  the  expense,  above,  of  the  internal  plate,  below,  of  the 
external,  and  fits  with  corresponding  bevelings  of  the  nasal  pro- 
cesses of  the  maxillary  bone.  Internally,  or  mesially,  the  bone 
articulates  with  its  fellow  of  the  opposite  side,  being  prolonged 
below  into  a  crest,  which  forms  a  part  of  the  nasal  septum,  and 
articulates  with  the  nasal  spine  of  the  frontal  above,  and  the 
ethmoidal  perpendicular  plate  below.  The  lower  border  is  free,  at 
least  so  far  as  any  bony  articulation  is  concerned,  giving  attachment 
by  a  thin,  sharp  edge  to  the  lateral  cartilage  of  the  nose.  A  notch, 
seen  at  the  centre  of  this  border,  transmits  the  nerve  occupying  the 
groove  on  the  inner  surface. 

THE  MALAPv  BONE. 


Fig.  14.— The  Malar  Bone. 


The  malar,  or  cheek  bones,  may  be  likened  to  two  bony  pads  laid 
on  either  lateral  aspect  of  the  face  for  the  purpose  of  influencing  a 
general  convexity.  Each  bone  is  ir- 
regularly quadrilateral,  supported 
above  by  articulation  with  the  frontal, 
sphenoid,  and  superior  maxillary 
bones ;  in  front  by  the  malar  process 
of  the  maxillary ;  posteriorly  by  the 
zygomatic  process  of  the  temporal. 

The  bone  presents  two  surfaces, 
four  processes,  and  four  borders.  The 
external  surface,  convex  and  smooth, 
presents  little  of  interest ;  the  fora- 
men, seen  upon  this  face,  is  some- 
times replaced  by  two  or  more  ;  they 
are  simply  the  orifices  of  canals,  trans- 
mitting unimportant  vessels.  The 
surface,  in  relationship,  is  mostly 
covered  by  the  orbicularis  palpebrarum  muscle,  while  the  zygomatici 
have  origin  from  the  lower  and  inner  aspect. 

The  internal  face  is  concave,  and  assists  in  forming,  above,  the 
temporal  fossa,  below,  the  zygomatic.  It  yields  partial  origin  to  both 
the  temporal  and  masseter  muscles. 

Of  the  four  processes,  the  orbital  is  the  most  interesting ;  turning 
at  right  angles  with  the  external  face  of  the  body,  it  assists  in  form- 


OUTERVIEWOF  THE  RIGHT  MALAR  BONE.    1, 

external  or  facial  surface;  2,  malar  fora- 
men;  3,  frontal  process;  -t,  5,  orbital  bor 
der;  6,  maxillary  border;  7,  zygomatic 
process;  8,  temporal  border;  9,  inferior 
border. 


54 


ORAL  DISEASES  AND   SURGERY. 


ing  a  portion  of  the  outer  wall  of  tlie  orbit  and  orbital  ridge.  The 
frontal  is  thick  and  serrated,  and  articulates  with  the  external  angu- 
lar process  of  the  frontal  bone.  The  ma.x'illary  is  rough,  and  trian- 
gular in  shape,  and  attaches  the  bone  in  front.  The  zygomatic  is 
sharp  and  flat,  and  forms  part  of  the  yoke  overlying  the  ridge  sep- 
arating the  zygomatic  from  the  temporal  fossa. 

The  four  borders  are  the  orbital,  the  maxillary,  zygomatic,  and 
temporal.  These  borders  correspond  with  the  relations  named,  but 
have  no  interest  apart  from  the  processes. 

THE   LACHRYMAL    BONE. 


Fig.  15.— The  Lach- 
rymal Bone. 


Looking  at  the  view,  or,  much  better,  at  the  articulated  skull,  the 
lachrymal  bone  is  seen  to  occupy  a  position  of  some  prominence  in 
the  composition  of  the  orbit.  A  ridge  on  its 
anterior  surface  divides  the  bone  into  two  parts  : 
one  part,  called  its  orbital  face  (bounded  above 
by  the  orbital  face  of  the  horizontal  plate  of  the 
frontal  bone ;  laterally,  by  the  os  planum  of 
the  ethmoid ;  below,  by  the  orbital  surface  of 
the  maxillary  bone),  enters  into  the  compo- 
sition of  the  orbital  cavity.  The  face,  to  the 
inner  side  of  the  ridge,  is  smooth  and  concave, 
and  articulates  with  the  nasal  process  of  the 
maxillary  bone,  internally,  and  with  the  lach- 
rA'mal  process  of  the  turbinated,  below;  these 
three  bones  in  their  union  form  the  ductus  ad 
nasum,  or  lachrymal  canal,  transmitting  the 
tears  to  the  inferior  meatus. 

The  bone,  by  its  internal  or  nasal  surface, 

enters    into   the    composition    of  the    middle 

meatus,  and  assists  in  closing  in  the  anterior 

ethmoidal  cells.     Like  the  external  surface,  it  is  divided  into  two 

faces,  the  line  of  division  being  a  depression  corresponding  with  the 

ridge  on  the  opposite  surface. 

Only  one  muscle  has  its  attachment  to  this  bone, — the  tensor  tarsi. 


External  view  of  the 
right  lachrymal  bone.  1, 
orbital  surface ;  2,  lachry- 
mal fossa;  3,  small  process 
bounding  the  latter  inte- 
riorly ;  4,  frontal  border ; 
5,  ethmoidal  border ;  6,  max- 
illary border ;  7,  process 
articulating  with  the  tur- 
binated bone. 


THE   HYOID   BONE. 


The  OS  hyoides  is  the  bone  situated  on  the  anterior  part  of  the 
neck  between  the  chin  and  sternum.     In  shape  it  somewhat  resem- 


ANATOMY  OF  THE  MOUTH  AND   FACE. 


55 


bo<ly  ;    2,  greater  horn  ; 
horn. 


bles  the  ordinary  horseshoe,  and  is  held  in  place  entirely  by  a  series 
of  antagonizing  muscles,  of  which  it  gives  attachment  to  some  ten 
pairs.  A  glance  at  the  bone  naturally  divides  it  into  a  body  and 
four  processes  or  horns ;  the  greater  of  these  cornua  extend  quite 
widel}^  over  the  lateral  aspect  of  the  neck, 

giving  attachment  to  the  hyo-glossus,  Fro.  16.— TheHyoid  Bone. 
middle  constrictor  of  the  pharynx,  and 
thyro-hyoid  muscles,  and  by  a  bulb,  con- 
stituting its  extremity,  to  the  thyro-hyoid 
ligament ;  it  also  serves  as  our  best  guide 
to  the  position  of  the  lingualis  artery. 
The  lesser  cornua  are  simply  two  conical 
eminences,   more   or   less   prominent   on 

different  specimens  ;  starting  out  at  the  point  of  junction  of  the 
great  horns  with  the  body,  they  look  upward  toward  the  chin,  and 
serve  to  afford  attachment  to  the  stylo-hyoid  ligaments. 

The  body  is  irregularly  quadrilateral  in  shape,  convex  in  front, 
concave  behind.  A  crucial  ridge,  the  intermuscular,  divides  the 
front  face  into  four  fossa.  This  surface  is  exclusively  devoted  to 
the  attachment  of  muscles  ;  above,  to  the  genio-hyoid  and  the  genio- 
hyo-glossus ;  below,  to  the  stylo-hyoid,  mylo-hyoid,  and  digastricus. 
The  posterior  surface  is  smooth  and  concave,  and  occupies  a  position 
just  in  front  of  the  epiglottis,  being  separated  from  it  above  by  some 
cellular  tissue  and  a  membrane  called,  from  its  relationship,  the 
thyro-hyoid. 


Fig.  17. 


Antero-posterior  section  of  the  cranium,  exhibiting  the  mode  by  which  the  con- 
nection of"  the  different  bones  contributes  to  preserve  its  integrity.  1,  parietal  bone  ; 
2,  frontal  bone ;  3,  its  orbital  plate  ;  4,  frontal  sinus ;  5,  body  of  sphenoid  bone ;  6, 
sphenoidal  sinus;  7,  occipital  bone;  8,  marginal  ridge  of  the  occipital  foramen. 


56  ORAL  DISEASES  AND   SURGERY, 

Tig.  18. 


View  of  the  right  half  of  the  base  of  the  skcll.  1,  palate 
plate  of  the  superior  maxillary  boue ;  2,  palate  plate  of  the 
palate  bone ;  3,  vomer ;  4,  iuternal  pterygoid  process ;  5,  ex- 
ternal pterygoid  process ;  6,  pyramidal  process  of  the  palate 
bone  ;  7,  under  surface  of  the  great  wing  of  the  sphenoid  bone  ; 
8,  its  temporal  surface ;  9,  zygomatic  arch  ;  10,  zygomatic  pro- 
cess of  the  malar  bone:  11,  zygomatic  process  of  the  temporal 
bone  ;  12,  squamous  portion  of  the  temporal  bone ;  13,  glenoid 
tubercle ;  14,  glenoid  cavity ;  15,  vaginal  process,  its  outer 
border  constituting  the  auditory  process  ;  16,  styloid  process  ; 
17,  external  auditory  meatus;  18,  mastoid  process;  19,  digas- 
tric groove;  20,  basilar  process  of  the  occipital  bone  co-ossified 
with  the  body  of  the  sphenoid  bone;  21,  condyle;  22,  occipital 
protuberance ;  23,  superior,  and  24,  inferior  semicircular  ridges ; 
25,  occipital  foramen  ;  2C,  incisive  foramen ;  27,  posterior  pala- 
tine foramen ;  2S,  spheno-niaxillary  foramen ;  29,  posterior 
naris;  30,  oval  foramen;  31,  spinous  foramen;  32,  lacerated 
foramen  ;  33,  Eustachian  tube  ;  34,  carotid  canal ;  35,  jugular 
foramen ;  3G,  stylo-mastoid  foramen ;  37,  3S,  foramina  for 
veins. 


CHAPTER    II. 


THE  MOUTH. 


Studying  the  month  from  the  living  subject,  we  remark,  first,  an 
entrance  of  two  fleshy  folds,  the  lips  ;  separating  these,  we  are  met 
by  a  second  portal,  the  teeth  ;  the  space  existing  between  these  two 
entrances  is  called  the  hull  or  vestibule  ;  opening  this  inner  gate- 
way, by  depressing  the  lower  jaw,  we  are  introduced  into  the  oral 
cavity  proper. 

The  mouth  is  the  commencement  of  the  alimentary  canal.  It  has 
as  oflRces,  expression  in  sound,  the  reception  of  food,  gustation, 
mastication,  and  insalivation  ;  consequently  must  possess  organs 
and  agencies  pertinent  to  these  ends. 

Looking  into  the  mouth,  we  observe  that  it  is  an  oval  cavity, 
bounded  posteriorly  by  a  veil  or  curtain.  This  falls  obliquely 
toward  the  fauces,  having  a  central  pendulum,  terminating  laterally 
in  arched  curves.  We  can  see  beneath  this  veil,  or  between  it  and 
the  base,  and  thereby  recognize  the  cavity  we  are  viewing  to  be 
simply  the  commencement  of  a  canal.  Every  part  of  the  cavity  we 
remark  to  be  covered  by  a  common  membrane,  which  membrane  we 
find  to  associate  externally  on  the  lips  with  the  skin  ;  internally  we 
see  it  passing  back  of  the  veil  down  the  throat, — this  is  a  mucous 
membrane,  and  examination  reveals  it  to  be  continuous  from  this 
cavity  to  the  outlet  of  the  rectum.  The  teeth,  thirty-two  in  number 
in  the  adult,  are  placed  in  two  harmonizing  or  articulating  arches  or 
curves,  and  are,  in  shape  or  character,  correspondent  with  omniv- 
orous habits.  Thus  certain  of  their  number,  the  incisors,  as  they 
are  called,  are  so  arranged  as  to  cut  or  incise.  Certain  others,  the 
cuspidati  or  canines,  are  spear-shaped,  and  tear  or  lacerate.  Still 
others,  the  bicuspidati  and  molars,  have  broad  and  roughened  sur- 
faces, acting  the  part  of  grinders.  The  tongue,  a  muscular  body, 
rests  within  the  lower  dental  arch  ;  it  evidently  is  fitted  and  suited 
to  preside  over  the  labor  of  the  teeth,  receives  or  rejects  articles  to 
be  comminuted,  places  and    retains  such  articles  in  position  to  be 

(57) 


58  ORAL  DISEASES  AND   SURGERY. 

masticated,  and,  when  ready  to  be  swallowed,  rolls  up  masses  into 
a  bolus,  and  passes  them  into  the  pharynx. 

The  roof  of  the  cavity,  beijinning  with  the  palatine  faces  of  the 
teeth,  is  made  up  evidently  of  hard  and  soft  tissues.  The  hard  por- 
tion we  discover  to  be  the  flesh-covered  alveolar  and  palatine  pro- 
cesses of  the  superior  maxillary  bones  and  the  palate  processes  of 
the  palate  bones.  The  soft  portion  dissection  reveals  to  be  a  simple 
attached  basement  tissue  covered  with  the  common  membrane. 

The  uvula,  the  central  pendulous  termination  of  the  soft  palate, 
consists  of  two  symmetrical  muscles  inclosed  in  the  common  mucous 
membrane.  The  office  of  this  body  is  to  act  as  an  agent,  exciting  the 
act  of  deglutition.  It  draws  the  veil  against  the  upper  wall  of  the 
pharynx,  thus  closing  the  posterior  nares  during  the  process  of  swal- 
lowing. In  the  production  of  loud  declamation  and  the  guttural 
forms  of  language,  it  is  supposed  to  modify  speech  by  lessening  the 
pharyngo-nasal  passage  when  it  acts  as  an  elevator  ;  this  elevating 
force  being  most  exhibited  in  the  highest  ranges  of  the  singing  voice, 
and  least  in  the  lower  keys. 

Continuing  to  look  for  a  short  period  into  the  mouth,  we  observe 
that  jets  of  fluid  are  occasionally  sent  up  from  the  anterior  floor  just 
back  of  the  lower  central  teeth.  We  also  see  drops  constantly  issuing 
from  an  orifice  situated  on  the  cheek  by  the  side  of  the  superior 
second  molar  tooth.  This  fluid  is  the  salivary  secretion,  and  comes 
from  glands  situated  in  the  imaiediate  neighborhood.  Besides  this 
salivary  fluid,  pearly  drops  are  seen,  more  or  less  plainly,  over  the 
surface  of  the  common  mucous  membrane.  This  is  mucus,  and  is 
the  product  of  the  follicles,  crypts,  or  glands  of  the  common  mem- 
brane. 

The  mouth,  then,  we  may  say,  is  made  up  of,  and  invites  a  study 
of,  the  lips,  cheeks,  gums,  teeth,  mucous  membrane,  tongue,  hard 
and  soft  palate,  and  salivary  glands  ;  and  if  we  accept,  as  indeed 
surgically  we  must,  that  the  cavity  begins  with  the  lips  and  ends 
at  the  posterior  wall  of  the  pharynx,  then  we  include  in  the  study 
all  the  relations  which  belong  to  the  posterior  entrance. 

The  lips  and  cheeks  are  alike  in  their  composition,  and  are  truly  a 
part  and  parcel  of  each  other.  First,  in  the  dissection,  we  have  a 
layer  of  skin  on  the  outside  and  a  layer  of  mucous  membrane  on 
the  inside.  Removing  the  skin,  we  expose  a  layer  of  cellular  fascia, 
in  which  is  more  or  less  fatty  tissue.  This  superficial  fascia,  as  it 
is  called,  differs  from  other  fasciae  of  the  same  signification,  in  not 
being  a  distinct  or  laminated  tissue.     It  is  intimatelv  connected  with 


THE  MOUTH. 


59 


the  skin,  and  more  intimateh''  associated  with  the  muscles.  Re- 
moving- this,  a  complex  grouping  of  muscles  is  exposed, — the  mus- 
cles of  expression. 

The  view  (Fig.  19)  expresses  so  fully  the  position  and  signification 
of  these  muscles  that  it  scarcely  seems  necessary  to  enter  on  any 

Fig.  19. — 3Iuscles  of  the  Face. 


Muscles  of  the  head  and  neck.  l,2,occipito-frontal  muscle:  l,it8  frontal  belly;  2,  its 
occipital  belly;  3,  nasal  pyramidal  muscle;  4,  superior,  and  5,  posterior  auricular  mus- 
cles;  7,  labio-nasal  elevator;  8,  elevator  of  the  upper  lip;  9,  nasal  compressor;  10,11, 
zygomatic  muscles  ;  12,  masseter  muscle  ;  13,  buccinator ;  14,  depressor  of  the  oral  angle  ; 
15,  oral  orbicular  muscle  ;  16,  elevator  of  the  oral  angle;  17,  18,  depressor  of  the  lower 
lip;  19,  sterno-mastoid  muscle;  20,  trapezius;  21,  posterior  belly  of  the  digastric  and  the 
stylo-hyoid  muscle;  22,  anterior  belly  of  the  former;  23,  loop  of  fibrous  tissue  attach- 
ing the  tendon  of  the  digastric  muscle  to  the  hyoid  bone;  24,  omo-hyoid  muscle;  25, 
sterno-hyoid ;  26,  sterno-thyroid,  seen  to  the  outer  side  and  behind  the  anterior  belly  of 
the  omo-hj'oid ;  27,  mylo-hyoid  ;  28,  splenius  ;  29,  elevator  of  the  scapular  angle ;  30,  31, 
middle  and  anterior  scalene  muscles  ;  32,  clavicle. 


description  of  them.  The  orbicular,  or  sphincter  of  the  lips,  may, 
however,  be  specially  noted,  as  its  influence  is  concerned  in  retract- 
ing wounds  of  the  part.  In  studying  the  muscles  of  the  face,  it 
will  be  observed  that  they  naturally  arrange  themselves  into  groups. 


60 


ORAL  DISEASES  AND  SURGERY. 


Thus  we  have  a  group  that  are  elevators,  another  that  are  depressors. 
Then  groups  that  pertain  to  particular  regions,  as  the  nasal,  superior 
maxillary,  inferior  maxillary,  intermaxillary,  etc.  Surgically,  how- 
ever, the  information  they  possess  is  sufficiently  elicited  in  com- 
prehending their  general  plan  and  arrangement. 

Situated  upon,  and  running  among  these  muscles,  we  have  the 
arteries  of  the  face.  These  are  all  branches  of  the  external  divi- 
sion of  the  common  carotid,  and  will  be  found  in  the  dissections 
distributed   exactly  as   seen    in   the  view.      The   facial,  the    third 

Fig.  20. — Arteries  of  the  Face. 


The  external  carotid  artery  and  its  branches.  1,  right  common  carotid  ;  2,  internal 
carotid;  3,  external  carotid;  4,  superior  thyroid;  5,  lingual;  6,  facial ;  7,  suhmontal ;  8, 
inferior  coronarj' ;  9,  superior  coronary  ;  10,  muscular  branches  ;  11,  lateral  nasal  artery ; 
12,  angular  artery;  13,  occipital  artery;  14,  descending  cervical;  15,  muscular  branch; 
16,  posterior  auricular  arteVy  ;  17,  parotid  branches  ;  18,  internal  maxillary  ;  19,  temporal ; 
20,  transverse  facial;  21,  anterior  auricular;  22,  supraorbital ;  23,  middle  temporal;  24, 
anterior  temporal ;  25,  posterior  temporal  artery. 


branch  of  the  carotid  externus,  is  observed  to  cross  over  the  lower 
jaw  just  in  front  of  the  masseter  muscle  ;  and,  in  the  subject,  is  seen 
to  emerge  from  or  beneath  the  submaxillary  gland,  generally  pass- 
ing through  its  substance.     Its  branches  are  ten  in  number;  four 


THE  MOUTH. 


61 


are  offshoots  from  its  cervical  portion  ;  six  are  facial.  The  facial 
branches  are,  first,  the  inferior  labial — which  passes  forward  under  the 
depressor  anguli  oris,  and  supplies  the  lower  part  of  the  lip,  anasto- 
mosing with  all  the  subjacent  vessels ;  the  submental,  inferior  coro- 
nary, and  inferior  dental  arteries.  The  coronaries — the  second  and 
third  of  these  branches — penetrate  the  substance  of  the  underlying 
muscles,  and  pass  around  the  lips  immediately  beneath  the  mucous 
membrane ;  their  pulsatious  may  be  very  plainly  felt ;  in  many  per- 
sons these  vessels  are  of  such  large  size  as  to  render  hemorrhage 
from  them  a  matter  of  some  trouble  to  control. 

Fig.  21. — The  Common  Carotid,  with  its  Divisions. 


Left  common  carotid  dividing  into  the  external  and  internal  carotid  arteries.  1, 
common  carotid  artery ;  2,  interniil  carotid  ;  3,  external  carotid  ;  4,  superior  thyroid ;  5, 
lingual ;  6,  pharyngeal  artery ;  7,  facial ;  8,  inferior  palatine  and  tonsillar  arteries ;  9, 
submaxillary ;  10,  submental ;  11,  occipital ;  12,  posterior  auricular ;  13,  parotid  branches  ; 
14,  internal  maxillary;  15,  temporal  artery;  16,  subclavian  artery;  17,  axillary;  18,  ver- 
tebral artery  ;  19,  thyroid  axis ;  20,  inferior  thyroid  giving  off  the  ascending  cervical ;  21, 
transverse  cervical;  22,  suprascapular;  23,  internal  mammary  artery. 


The  lateralis  nasi,  the  fourth  of  the  branches,  ascends  along  the 
side  of  the  nose,  supplying  its  alse  and  dorsum.  The  fifth,  ttie 
angular,  passes  between  the  inner  canthus  and  nasal  bridge.  It 
gives  off  sub-branches  to  the  orbicularis  muscle,  to  the  lachrymal 


62  ORAL  DISEASES  AND   SURGERY. 

sac,  and  to  the  integument  of  the  suborbital  region,  and  finally 
loses  itself  in  an  anastomosis  with  the  ophthalmic  artery.  A  point 
in  the  view  to  observe  is,  that  the  inferior  and  all  the  mesial  line  of 
the  face  is  supplied  by  branches  of  a  common  trunk,  and  that  this 
trunk  is  con)pressible  on  the  lower  jaw  just  in  front  of  the  masseter 
muscle,  facial, hemorrhage  being  thus  perfectly  under  control  by  com- 
pression. 

THE  NERVES  OF  THE  FACE. 

The  view  (Fig.  22)  beautifull}^  exhibits  the  distribution  of  the 
branches  of  the  facial  nerve.  The  main  trunk,  seen  emerging  just 
below  the  lobe  of  the  ear,  in  front  of  the  anterior  border  of  the  sterno- 
cleido-mastoideus,  is  the  portio  dura,  or  hard  portion  of  the  seventh 
nerve,  the  motor  nerve  acting  on  the  muscles  of  expression.  The 
nerve  arises  from  the  medulla  oblongata,  passes  outward  over  the  crus 
cerebelli,  and  enters  the  auditory  meatus  with  the  soft  or  auditory 
portion  ;  passing  to  the  bottom  of  this  meatus,  it  enters  the  Fallopian 
aqueduct,  follows  the  serpentine  course  of  this  canal  until  it  arrives 
at  the  stylo-mastoid  foramen,  whence  it  emerges,  as  seen,  upon  the 
outside  of  the  face ;  while,  however,  in  the  temporal  bone,  the 
nerve  connects  with  several  others,  and  forms  a  ganglion,  the  intu- 
mescentia  gangliformis,  as  it  is  called. 

Issuing  from  the  stylo-mastoid  foramen,  the  facial  associates  with 
the  pneumogastric,  glosso-pharN^ngeal,  carotid  plexus,  auricularis 
magnus,  and  auriculo-temporal.  Passing  to  the  face,  it  unites  with 
the  three  divisions  of  the  fifth  nerve. 

In  front  of  the  ear  the  nerve  is  seen  to  divide  into  two  primary 
divisions  or  trunks,  the  temporo-facial  and  cervico-facial.  The  tem- 
poral, the  larger  of  the  two,  passes  through  the  parotid  gland, 
crosses  the  neck  of  the  lower  jaw,  and  divides  into  three  sets  of 
branches,  distributed  to  the  temporal,  malar,  and  infraorbital  regions. 
The  cervico-facial  passes  downward  and  forward  through  the  gland, 
and  divides  into  buccal,  supra-  and  inframaxillary  branches.  The 
manner  of  distribution  and  anastomosis  is  perfectly  shown  in  the 
dissection.  The  facial,  being  a  motor  nerve,  has  its  distribution 
exclusively  in  muscular  tissue:  injury  to  this  nerve  exhibits  its 
results  in  the  altered  expression  of  the  face  in  paralysis  following  its 
destruction. 


THE  MOUTH. 

Fig.  22. — Nerves  of  the  Face. 


63 


1,  trunk  of  the  nerve  emerging;  ut  the  stylo-iiiastoki  foramen  ;  2,  its  deep  auricular 
branch ;  3,  anastomosis  of  the  latter  with  the  great  auricular  nerve  of  the  cervical 
l^lexus  ;  4,  5,  6,  branches  to  the  contiguous  muscles ;  7,  8,  branches  of  the  facial  to  the 
digiistric  and  stylo-hjoid  muscles  ;  9,  temporo-facial  division  of  the  nerve ;  10,  branch  to 
the  temple,  anastomosing  witli  the  auriculo-temporal  nerve ;  11,  temporal  branches  ;  12, 
zygomatic  brandies ;  13,  infraorbital  branches ;  14,  15,  cervico-facial  division  of  the 
facial  nerve  ;  14,  buccal  branches ;  16,  inferior  maxillary  branches  ;  17,  cervical  branches ; 
18,  auriculo-temporal  nerve;  19,  20,  terminal  branches  of  the  frontal  nerve;  21,  terminal 
branch  of  the  lachrymal  nerve;  22,  external  nasal  nerve;  23,  branch  of  the  temporo- 
malar  nerve;  24,  terminal  branch  of  the  internal  nasal  nerve;  25,  infraorbital  nerves; 
26,  anastomosis  between  the  buccal  branch  of  the  inferior  maxillary  nerve  and  the  buccal 
branches  of  the  facial  nerve  ;  27,  terminal  bi  auches  of  the  inferior  dental  nerve ;  28,  great 
occipital  nerve  ;  29,  31,  branches  of  the  great  auricular  nerve ;  30,  small  occipital  nerve ; 
32,  superficial  cervical  nerve,  anastomosing  with  the  facial  nerve. 


THE  VEINS  OF  THE  FACE. 

The  veins  of  the  face  will  be  seen  to  correspond  quite  closely 
with  the  arterial  distribution.  Surgically  they  are,  however,  of 
little  import,  as  it  is  seldom  that  wounds  of  them  are  of  sufBcieut 


64 


ORAL  DISEASES  AND  SURGEBY, 


consequence  to  command  any  direct  attention  ;  they  pass  their  blood 
into  one  or  another  of  the  three  jugulars,  being-  not  by  any  means 


Fig.  23. — Veixs  of  the  Face. 


Veins  of  the  he*.d  axd  neck.  1,  front.U  veiu  ,  -J,  iuishI  vein;  3,  4,  labial  veins;  5, 
facial  vein;  6,  lingual  \ein;  7,  internal  jiigul.ir  vein ;  8,  9,  posterior  and  anterior  tem- 
poral veins ;  10,  transverse  facial  vein ;  IX,  internal  maxillary  vein  ;  12,  posterior  auricu- 
lar vein  ;  13,  external  jugular  vein ;  14,  posterior,  15,  anterior  jugular  veins,  a,  external 
carotid  artery;  6,  sterno-mastoid  muscle;  c,  trapezius;  d,  pectoral  muscle;  e,  deltoid 
muscle. 


constant  in  the  selection.     Between  them  all,  however,  the  most 
thorough   anastomosis  is  always  found  to  exist,  thus  rendering  it 


THE  MOUTH.  65 

really  of  little  consequence  what  may  be  the  direct  downward  course 
of  the  current.  The  veins  of  the  antero-exterior  head  are  the  facial, 
the  temporal,  the  internal  maxillary,  and  the  temporo-maxillary. 

The  facial,  commencing-  at  the  inner  angle  of  the  orbit,  is  formed 
by  the  confluence  of  the  supraorbital,  palpebral,  nasal,  and  angular 
veins.  It  commences  its  course  downward  and  outward,  passing 
beneath  the  zygomatic  muscles,  receiving  the  superior  and  inferior 
labial  veins,  the  buccal,  and  the  masseteric ;  passes  to  the  base  of  the 
jaw,  receiving  just  below  it  the  submental,  the  inferior  palatine,  the 
submaxillary,  and  the  ranine  veins,  and,  finally,  with  a  great  branch, 
received  from  the  temporo-maxillary,  loses  itself  in  the  deep  jugular. 

The  temporal  commences  by  a  plexus  on  the  side  of  the  head  and 
vertex,  passes  downward  in  front  of  the  ear,  receives  the  transverse 
facial,  posterior  auricular,  occipital,  and  deep  maxillary  veins,  enters 
the  substance  of  the  parotid  gland,  and,  finally,  being  enlarged  by 
these  various  branches,  becomes  the  external  jugular. 

The  internal  or  deep  maxillary  is,  in  its  origin,  a  series  of  veins 
collecting  the  blood  from  the  parts  supplied  by  the  internal  maxil- 
lary artery  and  adjacent  parts.  These  various  veins,  the  middle 
meningeal,  deep  temporal,  pterygoid,  masseteric,  buccal,  and  inferior 
dental,  forming  the  common  trunk,  empty  into  the  temporal. 

The  temporo-maxillary  is  simply  the  name  given  to  that  part  of 
the  temporal  vein  below  the  point  of  entrance  of  the  maxillary — 
either  name  is  used  with  equal  propriety. 


SECTIONAL  EXPKESSION  OF  THE  MOUTH. 

The  view  (Fig.  24)  represents  a  section  directly  through  the  centre 
of  the  skull  from  before  backward,  and  perfectly  exhibits  the  char- 
acter of  the  mouth  and  its  associations.  Below  is  seen  the  tongue 
in  its  relations,  in  front,  to  the  genial  tubercles ;  behind,  to  the  epi- 
glottis. A  fossa  between  the  root  of  this  organ  and  the  epiglottis, 
one  on  each  side  of  a  common  centre,  the  fraanum  epiglottidis,  is  par- 
ticularly worthy  of-  note,  as  it  is  a  frequent  receptacle  for  fish-bones 
and  other  foreign  bodies,  giving  sometimes  much  trouble  in  their 
removal.  The  free  surface  of  the  tongue  is  seen  to  be  convex,  while 
the  section  reveals  its  common  body  to  be  triangular  with  the  apex, 
looking  forward. 

The  roof  of  the  mouth,  seen  above,  is  remarked  to  be  a  quite  thin 
plane,  forming  as  well  the  floor  of  the  nose.  Its  relation  to  the  oral 
cavity  is  concave,  but  differs  widely  in  various  persons,  being  in 

5 


66 


ORAL  DISEASES  AND   SURGERY. 


some  almost  flat,  in  others  very  deep.  The  anterior  portion,  bony, 
will  be  recognized  as  being  formed  by  the  palatine  processes  of  the 
maxillary  and  palate  bones ;  the  posterior  portion,  soft,  veil-like,  and 

Fig.  24. — Skctional  View  or  the  Nose,  Mouth,  and  Pharynx. 


Vertical  section  of  the  face  and  neck,  through  the  median  line  antero-posteriorly, 

EXPOSING   TO   VIEW   THE   NOSE,   MOUTH,  PHARYNX,  AND   LARYNX.      1,  OVal  Curtilage  of  the  left 

nostril ;  2,  triangular  cartilage  ;  3,  line  of  separation  between  the  two  ;  i,  prolongation  of 
the  oval  cartilage  along  the  column  of  the  nose  ;  5,  superior  meatus  of  the  nose  ;  6,  middle 
meatus  ;  7,  inferior  meatus ;  8,  sphenoidal  sinus  ;  9,  posterior  part  of  the  left  uasal  cavity, 
communicating  with  the  pharynx  ;  10,  orifice  of  the  Kustachian  tuhe;  11,  upper  extremity 
of  tlie  pharynx;  12, soft  palate,  ending  below  in  the  uvula;  13,  interval  of  the  mouth  be- 
tween the  lips  and  jaws  ;  14,  roof  of  the  mouth,  or  hard  palate  ;  15,  communication  of  the 
cavity  of  the  mouth  with  the  interval  between  the  jaws  and  cheek  ;  16,  tongue  ;  17,  fibrous 
partition  in  the  median  line  of  the  latter;  18,  genio-glossal  muscle;  19,  genio-hyoid 
muscle;  20,  mylo-hyoid  muscle:  21,  anterior  half  arch  of  the  palate;  22,  posterior  half 
arch  of  the  palate ;  23,  tonsil ;  24,  25,  floor  of  the  fauces  ;  26,  27,  pharynx  ;  28,  cavity  of 
the  larynx ;  29,  ventricle  of  the  larynx ;  30,  epiglottis ;  31,  hyoid  bone ;  32,  33,  thyroid 
cartilage;  34,  thyro-hyoid  membrane;  35,  36,  cricoid  cartilage;  37,  vocal  membrane. 


movable,  is  the  velum,  terminating  in  the  uvula  in  the  centre,  just 
above  and  in  front  of  the  tip  of  the  epiglottis;    laterally,  in  two 


THE  MOUTH. 


67 


pillars  or  half  arches,  called  respectively  the  anterior  and  posterior 
pillars.  The  first  of  these — the  one  seen  in  the  view  as  associating 
itself  with  the  tongue — is  formed  by  the  projection  of  the  palato- 
glossus muscle;  the  second,  or  posterior,  is  the  projection  likewise 
of  a  muscle,  the  palato-pharyngeus,  passing  from  the  veil  to  the 
pharynx  ;  the  fossa  existing  between  these  pillars  lodges  the  tonsil 
gland.  The  hard  portion  of  the  palate,  or  oral  roof,  is  frequently  the 
seat  of  necrosis  ;  it  will  be  remarked  that  only  a  very  small  loss  of 
substance  is  required  to  associate  the  two  cavities.  The  isthmus  of 
the  fauces,  the  space  between  the  two  arches,  is  bounded,  above,  by 
the  margin  of  the  palate  ;  below,  by  the  base  of  the  tongue  ;  laterally, 
by  the  half  arches  and  amygdalae. 

The  Tonsils. — The  tonsils  are  glandular  organs,  situated  one  on 
either  side  of  the  isthmus.  These  bodies  are  made  up  of  many  lob- 
ules, having  many  sulci  lined  by  involutions  of  the  common  mucous 
membrane.  They  are  not  unfrequently  the  seat  of  such  hypertrophy 
as  to  make  necessary  their  amputation,  while  in  their  sulci  may  lodge 
debris,  which,  in  its  retention  and  decomposition,  becomes  one  of  the 
sources  of  an  unpleasant  breath.  Externally  these  bodies  are  in 
very  close  relation  with  the  internal  carotid  arteries,  a  point  neces- 

FiG.  25. — SiDK  View  of  the  Muscles  of  the  Tongue. 


1,  2,  stylo-glossal  muscle;  3,  lingual  muscle;  4,  upper  part  of  the  tongue;  5  6,  hyo- 
glossal muscle;  7,  genio-glossal  muscle;  8, stylo-phavyngeal  muscle;  9,  genio-hyoid  mus- 
cle ;  10,  11,  median  line  of  the  mylo-hyoid  muscles. 

sary  to  be  kept  in  remembrance  in  performing  operations  on  them. 
(See  Tonsil  Glands.) 


68 


ORAL  DISEASES  AND   SURGERY. 


The  relationship  of  a  bolus  of  food  with  the  pharynx,  and  its 
direction,  over  the  chink  of  the  glottis  into  the  oesophagus,  by  the 
epiglottis,  are  clearly  exhibited  by  the  drawing. 

The  Tongue. — Dissection  of  the  tongue  reveals  it  to  be  a  some- 
what complex  body,  although  made  up  in  the  great  mass  of  its  bulk 


Fig.  2G. — Upper  Surface  of  the  Tongue. 


'- .." ^-^iia^ga^aiaa*'^ 


1,  2,  V-Iike  row  of  tlie  ciiciinivallate  iiapill.v ;  3,  capitate  papillie;  4,  5,  conical  pa- 
pilla?; 6,  6,  floor  of  the  fauces,  with  numerou.s  simple  follicular  glands;  7,  tonsils;  8, 
summit  of  the  epiglottis  ;  9,  the  middle  glosso-epiglottic  frasnura,  with  depressions  on  each 
side  bounded  externally  by  the  lateral  frana. 


by  muscular  substance.     Attached  to  the  inferior  maxillary  bone  in 
front,  and  to  the  hyoid  behind,  it  yet  moves  with  the  greatest  free- 


THE  MOUTH.  69 

dom  and  latitude  in  either  direction,  giving  us  the  idea  that  if  it  is 
muscular  substance,  it  must  be  free  muscle  set  upon  fixed  muscles, 
and  this  is  practically  the  case,  as  is  understood  by  studying  a  dis- 
section. 

The  muscular  structure  of  the  tongue  is  made  up  of  five  distinct 
pairs  and  certain  non-attached  fasciculi.  The  body,  as  its  surface  is 
concerned,  is  seen  with  a  base  looking  backward  into  the  fauces, 
and  a  tip,  which  represents  the  apex  of  a  pyramid.  Beginning 
the  study  of  the  organ  Avith  its  relations  to  the  hyoid  bone,  we 
remark,  first,  that  from  this  bone  arises  a  muscle,  the  hyoglossus, 
which,  passing  almost  directly  upward,  enters,  with  the  stylo-glossus, 
the  root  of  the  body,  and  expands  itself  laterally  and  forward. 
Passing  toward  the  centre  of  the  bone,  we  remark  a  second  muscle, 
the  genio-hyoglossus,  which,  having  apparent  origin  from  the  genial 
tubercles,  radiates  downward  and  upward,  attaching  one  of  its 
wings  to  the  os  hyoides,  the  other  spreading  out  to  assist  in  the 
formation  of  the  tongue.  The  stylo-glossus,  the  third  muscle,  arises 
from  the  styloid  process  of  the  temporal  bone,  passes  downward 
and  forward,  and  occupies  or  makes  up  either  lateral  aspect  from 
the  tip  to  the  bone.  The  fourth,  the  lingualis,  seen  between  the 
stylo-glossus  and  genio-hyoglossus,  passes  from  the  tip  to  the  base, 
having,  indeed,  some  few  of  its  fibres  continued  to  ihe  os  hyoides. 
The  fifth,  the  palato-glossus,  is  the  muscle  of  the  anterior  half  arch; 
it  assists  in  forming  the  base  and  side.  The  unattached  fibres  are 
certain  longitudinal  and  transverse  bands  running  through  the  sub- 
stance of  the  organ.  The  tongue,  as  an  organ  of  nutrition,  is 
adapted  most  happily,  through  its  muscular  character,  to  preside 
over  the  act  of  mastication,  and,  this  process  completed,  to  transfer 
the  comminuted  mass  back  into  the  grasp  of  the  pharyngeal  con- 
strictors. Its  ability  and  variety  of  action  are  comprehended  by  a 
single  moment's  observation  of  the  dissection. 

Fig.  26,  exhibiting  the  magnified  upper  surface  of  the  organ,  dis- 
covers it  covered  with  mucous  membrane,  dotted  here  and  there 
with  more  or  less  regularly  located  papillae,  of  varying  size  and 
character. 

The  mucous  membrane  envelops  the  tongue  wherever  the  body 
has  free  surface.  Above,  it  is  dense,  and  affords  support  to  the 
papillse ;  below,  it  is  exceedingly  delicate,  and  is  traceable  through 
the  ducts  of  the  submaxillary  and  sublingual  glands. 

The  papillse,  seen  upon  the  dorsum,  are  cone-shaped  projections 
of  homogeneous  tissue,  holding  arteries,  reins,  and  nerves  in  plexi- 


70 


ORAL  DISEASES  AND   SURGERY. 


form   arrangement ;  they  are  located   in  three  distinct  sets,    each 
having  distinctive  features. 

The  most  posterior  are  the  largest,  and  occupy  a  position  which 
very  much  resembles  the  letter  V;  they  may  be  likened  to  inverted 
cones,  the  apices  resting  in  cup-shaped  depressions  of  the  mucous 
membrane,  hence  surrounded  each  by  a  valley.    They  are  variously 

Figs.  27  and  28 — Papillae  of  Tongue. 


Diagram  of  the  papilljE  op  the  tongue,  moderately  magnified.  1,  capitate  papillre ;  2, 
conical  papilla; ;  3,  epithelium  ;  4,  the  same  structure  forming  bunches  of  hair-like  pro- 
cesses ;  5,  connective  tissue. 


Papilla;  or  the  tongue,  highly  magnified.  1,  conical  papilla; ;  2,  capitate  papillae;  3, 
simple  papillae,  occupying  the  intervals  of  the  compound  papilla;;  4,  epithelium  ascend- 
ing from  the  conical  papilUc  in  hair-like  processes ;  5,  isolated  cpitlielial  scales  from  the 
latter. 


named.  The  maximae  or  circumvallatse  ;  of  this  class  there  are  some 
fifteen ;  the  elevated  margins  of  the  fossa  surrounding  these  papillae 
are  studded  with  secondary  papillae.  The  structure  of  these  bodies 
is  accurately  exhibited  in  the  magnified  drawing. 

The  papillae  fungiformes  or  mediae  are  scattered  somewhat  irregu- 
larly over  the  sides  and  apex  of  the  organ  ;  they  are  exceedingly 
vascular,  and  closely  covered  with  secondary  papillae  ;  are  broad  and 
rounded  on  their  free  surfaces,  narrow  and  pointed  at  their  attach- 
ment to  the  tongue ;  their  middle  size  and  red  color  easily  distin- 


THE  MOUTH.  71 

guish  them.      The   magnified   fungiform    papillae  are  seen   in   the 
drawing. 

The  smallest  or  filiform  papillae  follow  somewhat  in  their  arrange- 
ment the  order  of  the  maximae,  being  interspersed  among  the  fungi- 
formes.  They  are  very  minute,  and  covered  so  deeply  with  epithe- 
lium as  to  appear  quite  white;  they  are  enveloped  with  secondary 
papillae,  as  exhibited  in  the  figure. 

In  the  tongue,  beside  these  papillae  are  found  also  numerous 
mucous  glands  ;  these  bodies,  scattered  over  the  whole  surface, 
secrete  the  ordinary  mucus  ;  they  differ  in  no  respect  from  mucous 
glands  wherever  situated.  In  the  valleys  surrounding  the  maximae 
papillai  these  glands  are  found  in  larger  number  than  in  any  other 
portion  of  the  organ. 

A  transverse  section  exhibits  the  tongue  as  composed  of  two  sym- 
metrical halves,  separated  from  each  other  by  a  fibrous  septum,  each 
half  consisting,  as  we  have  seen,  of  muscular  structure,  supplied 
with  vessels  and  nerves,  and  having,  in  most  cases,  much  interposed 
fat. 

The  tongue,  being  an  organ  of  both  special  and  common  sense,  is 
furnished  with  nerves  of  both  signification.  Thus  the  papillae,  at 
the  apex  and  sides,  are  supplied  with  the  gustatory  filaments  from 
the  third  branch  of  the  fifth  nerve  ;  the  great  papillae  and  base  of  the 
organ,  from  filaments  of  the  glosso-pharyngeal  ;  the  muscular  struc- 
ture, from  the  hypoglossal. 

The  arteries  of  the  tongue  are  the  lingual,  branches  of  the  facial, 
and  ascending  pharyngeal.  The  one  of  most  signification  is  the 
first.  This  vessel,  by  its  continuation  known  as  the  ranine,  anasto- 
moses with  its  fellow,  just  above  the  fraenum,  on  the  under  surface  of 
the  organ,  and  is  liable  to  be  opened  in  the  operation  for  tongue-tie. 
This  artery  is  the  second  branch  from  the  external  carotid  ;  it  pursues 
a  course  parallel,  for  a  short  distance,  with  the  great  horn  of  the  hyoid 
bone  lying  between  it  and  the  hypoglossal  nerve.  Wounds  of  the 
tongue  occasionally  make  the  vessel  at  this  point  the  seat  of  ligation. 

The  epiglottis,  seen  by  depressing  the  dorsum,  forms,  practically, 
the  base  of  the  organ,  being  supported  in  the  centre  by  a  bridle,  the 
fraenum  epiglottidis,  and  at  either  side  by  two  duplications  of  the 
lingual  mucous  membrane,  the  glosso-epiglottic  ligaments  or  folds, 
as  they  are  called  ;  these  boundaries  form  two  lateral  depressions  or 
fossae,  fossae  linguales,  noticed  as  being  so  frequently  the  seat  of  the 
lodgment  of  foreign  particles.  (See  Diseases  of  the  Tongue.) 

The  Gums. — See  Diseases  of  the  Gums. 


72  ORAL  DISEASES  AND  SURGERY. 

The  Mucous  Membrane. — Practically  considered,  the  oral  mucous 
membrane  is  to  be  viewed  as  commencing  at  the  lips  and  terminating 
at  the  anus,  so  much  is  it  in  sympathy  part  with  part.  Anatomically, 
we  view  this  membrane  as  consisting  of  a  plane  of  homogeneous 
tissue,  underlaid  by  its  vascular  supply,  the  vessel  being  supported 
by  aud  in  cellular  tissue.  This  basement  membrane  gives  support  to 
a  covering  of  squaiuis  or  scales,  known  as  the  epithelium,  and  covers 
in  tissues  or  organs  which  have  offices  of  a  recrementitial  nature. 

The  tissues,  besides  the  vascular,  which  underlie  the  mucous  mem- 
brane, are  the  nerves,  the  lymphatics,  and  the  papillary  structure. 
The  epithelium,  the  covering  tissue^  is  singularly  various  in  its  char- 
acter, being  in  some  parts  columnar,  in  others  squamous,  in  others 
ciliated. 

Commencing  at  the  alveolar  margin  of  the  lower  jaw,  this  mem- 
brane passes  over  the  floor  of  the  mouth,  envelops  the  tongue  on  all 
its  free  surface,  forming  beneath,  by  its  duplications,  the  frsenum 
linguae ;  from  the  back  of  the  organ  it  is  so  reflected  as  to  form  the 
three  glosso-epiglottic  fraena;  from  this  it  lines  the  pharynx  and 
larynx,  and  is  then  continued  over  the  digestive  and  respiratory 
tracks,  lining,  in  the  latter,  the  ver}"-  terminal  vesicles. 

The  mucous  cysts  or  follicles,  so  plentifully  scattered  over  the 
oral  mucous  surface,-  have,  as  their  office,  the  secretion  of  a  limpid 
fluid,  which  is  commonly  to  be  seen  standing  over  the  membrane  as 
drops  of  cold  sweat  are  observed  on  the  forehead  in  typhoid  con- 
ditions, the  two,  indeed,  looking  very  similar.  The  constituents  of 
mucus  are  water,  the  peculiar  organic  principle  called  mucosin;  and 
alkaline  salts.  Mucous  glands  are  variously  named,  according  to 
their  location,  as  glandulae  labiales,  buccales,  etc. 

Columnar  epithelium  consists  of  rod-like  particles,  crowded  closely 
together,  aud  bulged  near  the  centre  by  a  nucleus;  this  variety  is 
found  in  the  air-passages,  on  the  intestinal  villi,  in  the  bile  duct,  and 
elsewhere.  The  scaly  is  found  in  the  alimentary  tract  as  low  as  the 
stomach.  The  glandular  seems  to  be  a  constituent  of  all  the  glands, 
being  made  up  of  particles  bulky  and  globular.  Ciliated  epithelium 
is  the  columnar  variety  clothed  with  secondary  particles. 

THE   SALIVARY  GLANDS. 

The  salivary  glands  are  of  the  conglomerate  order,  and  are  very 
well  represented  b}^  an  ordinary  bunch  of  grapes.  There  is,  first,  a 
great  number  of  lobules,  each  lobule  being  a  miniature  gland  ;  from 


THE  MOUTH.  73 

these  come  ducts,  or  channels  of  outlet,  representing  the  grape- 
stems;  these  are  all  associated  with  a  common  branch  or  duct, 
which  is  the  channel  of  outlet  into  the  mouth. 

The  parotid,  the  largest  of  the  salivar}^  glands,  is  situated  in  the 
hollow  between  the  external  ear  and  ramus  of  the  inferior  maxillary 
bone.  Its  weight  varies  considerably  in  different  individuals,  the 
mean,  however,  being  in  the  neighborhood  of  an  ounce.  The  bound- 
ary of  the  gland  above  is  the  zygoma;  below,  a  line  carried  directly 
across  from  the  angle  of  the  jaw  to  the  sterno-mastoid  muscle.  Dis- 
sected from  its  bed,  the  organ  is  found  quite  deeply  seated ;  it  ex- 
tends above  into  the  glenoid  fossa  of  the  os  temporis,  and  below 
rests  upon  the  styloid  process  and  muscles,  extending  forward  to  the 
space  between  the  two  pterygoid  muscles.  The  gland  is  exceedingly 
vascular,  having  imbedded  in  it  the  external  carotid  artery,  which, 
in  its  substance,  divides  into  the  temporal,  internal  maxillary,  trans- 
verse facial,  and  posterior  auricular.  The  temporo-maxillary  vein 
also  traverses  the  structure,  while  the  deep  jugular  and  the  internal 
carotid  artery  lie  very  close  to  its  deep  surface ;  it  is  also  pierced  by 
the  facial  and  great  auricular  nerves.  Externally,  the  gland  is 
smooth,  and  has  its  lobes  protected  by  a  covering,  very  similar  in 
appearance  to  the  pia  mater  of  the  brain.  Upon  this  covering  lie 
two  lymphatic  ganglia,  the  enlargement  of  which  is  often  mistaken 
for  disease  of  the  gland  itself.  Covering  the  gland  is  the  parotid 
fascia,  a  reflection  simply  of  the  common  deep  fascia  of  the  neck, 
tlie  platysma  myoides,  fascia  superficialis,  and  skin.  The  gland 
empties  its  secretion  into  the  mouth  through  a  duct  knowu  as  that 
of  Steno.  This  passes  across  the  face  between  the  superficial  fascia 
and  muscles,  perforating  the  buccinator  opposite  the  second  molar 
of  the  upper  jaw.  A  line,  designating  the  position  of  the  duct,  and 
which  is  most  important  to  be  remembered,  is  drawn  from  the  lobe 
of  the  ear  to  the  middle  of  the  upper  lip.  This  duct  is  composed  of 
firm  aad  resisting  tissue,  is  about  the  diameter  of  a  crow-quill,  and 
is  some  two  inches  in  length;  it  consists  of  three  coats, — an  external 
or  fibro-muscular,  an  internal  or  mucous,  lined  with  ciliated  epithe- 
lial scales,  and  a  middle  or  cellular  coat. 

The  submaxillary,  the  second  in  size  of  the  salivary  glands,  is 
situated  beneath  the  lower  jaw  in  the  superior  cervical,  or  sub- 
maxillary, triangle.  The  gland  is  somewhat  of  the  size  and  shape 
of  an  almond-hull,  and  has  a  weight  of  two  or  three  drachms;  it  is 
completely  enveloped  by  a  triangular  envelope,  made  by  two  leaves 
of  the  deep  fascia  attached  below  to  the  digastric  tendon.     Directly 


74  ORAL  DISEASES  AND  SUBGERY. 

upon  the  gland,  and  within  the  envelope,  are  two  lymphatic  gan- 
glia, which  are  quite  liable  to  take  on  inflammatory  enlargement ; 
these  glands  I  believe  to  be  pretty  constant,  as  I  have  examined 
many  subjects  for  them,  and  mostly  with  the  common  result  of  seeing 
them.  The  so-called  extirpation  of  the  submaxillary  gland  is,  most 
generally,  the  removal  of  one  of  these  bodies  enlarged  through 
inflammatory  action;  these  ganglia  may  be  surgically  viewed  as 
being  strictly  non-vascular,  a  ligature  being  seldom  needed  in 
operations  upon  them.  The  gland  itself,  on  the  contrary,  is  very 
vascular,  the  facial  artery  passing  frequently  directly  through  its 
substance,  or  so  closely  connected  with  the  lower  surface  as  to 
compel  the  division  of  it,  or  some  of  its  large  branches,  before  the 
body  can  be  raised  from  its  bed;  the  lingualis  also  sends  branches 
to  it,  while  its  veins  correspond  with  the  arteries.  The  gland  is 
closely  in  relation  with  the  parotid,  behind,  and  the  lingual,  in  front, 
being  separated  from  the  first  by  the  stylo-maxillary  ligament,  and 
from  the  latter  by  the  mylo-hyoid  muscle.  The  duct  by  which  the 
gland  conveys  its  secretion  to  the  mouth  is  some  two  inches  in 
length;  it  passes  between  the  mylo-hyoid  and  genio-hyoid  muscles, 
and  opens  by  the  side  of  the  fraenum  linguae.  It  is  the  most  common 
seat  of  ranula.     The  duct  is  called  Wharton's  duct. 

The  sublingual  is  the  smallest  of  the  three  glands;  it  lies  directly 
beneath  the  mucous  membrane,  being  between  it  and  the  mylo-hyoid 
muscle;  its  weight  is  about  one  drachm.  The  exact  position  of  the 
gland,  as  it  lies  at  the  lateral  aspect  of  the  frsenum  lingua?,  can  be 
seen  by  raising  the  tip  of  the  tongue  ;  its  bulk  will  be  noticed  by  ele- 
vating the  mucous  membrane,  upon  which  its  excretory  ducts,  some 
twenty  in  number,  open  ;  these  ducts  are  called  ductus  Riviniani, 
and  are  to  be  distinguished  from  one  or  more,  called  the  Bartholin, 
opening  into  or  near  Wharton's  duct.  The  lingual  gland,  when  dis- 
eased, may  frequently  be  removed  with  very  little  hemorrhage.  I 
have  extirpated  it  without  using  a  ligature. 


TEMPORO-MAXILLAKY  ARTICULATION. 

The  inferior  maxillary  bone  articulates  with  the  anterior  portion 
of  the  glenoid  cavity  of  the  temporal,  forming  what  is  known  as  an 
arthrodial  or  gliding  joint.  The  direct  composition  of  this  joint 
consists  of  the  convex  condyloid  head  of  the  maxillary  bone,  the 
concave  surface  of  the  glenoid  fossa,  interarticular  fibro-cartilage,  a 


THE  MOUTH.  75 

double  synovial  membrane,  and  a  loose  capsular  ligament.    (See 
engraving.) 


Figs.  29  and  30. — Vertical  Section  of  Temporo-Maxillary  Articu- 
lation. 


/"V 


Vertical  section  of  the  articula- 
tion OF  the  lower  jaw.  1,  is  placed 
above  the  glenoid  cavity;  2,  glenoid 
cavity;  3,  interarticular  cartilage  di- 
viding the  joint  into  two  cavities,  4  and 
5 ;  6,  an  interarticular  cartilage  sepa- 
rated from  a  joint,  to  exhibit  its  form. 


External  view  of  the  temporo-maxillary 
ARTICULATION.  1,  zygoina ;  2,  glenoid  tubercle; 
3,  ramus  of  the  inferior  maxillary  bone ;  4, 
mastoid  process;  5,  external  lateral  liga- 
ment ;  6,  stylo-maxillary  ligament,  a  process 
of  the  cervical  fascia. 


The  double  character  of  the  glenoid  fossa,  with  its  fissure  of 
division,  its  articulating  eminence  in  front,  and  the  cartilage-covered 
condyle  of  the  maxillary  bone,  must  be  understood  by  looking  at 
the  bones.  The  view  represents  the  parts  in  position  and  physio- 
logical relation.  Above  is  seen  the  glenoid  cavity;  below,  the  con- 
dyle of  the  inferior  maxilla ;  between,  the  interarticular  fibro-carti- 
lage,  with  a  synovial  or  lubricating  membrane  lining  each  aspect  of 
the  joint :  the  back  part  of  a  common  capsular  ligament  is  also  seen, 
which,  when  complete,  would  be  exhibited  as  enveloping  the  whole 
joint.  Back  of  the  section,  as  shown  in  the  view,  is  that  portion  of 
the  cavity  which  lodges  the  upper  part  of  the  parotid  gland. 

The  capsular  ligament  is  an  exceedingly  loose  sac,  very  much, 
indeed,  like  the  capsule  of  the  humero-scapular  articulation ;  it  is 
attached  above  to  the  circumference  of  the  glenoid  cavity,  and  in 
front  to  the  articular  root  of  the  zygoma ;  below,  it  clasps  the  neck 
of  the  bone  just  beneath  the  head. 

The  interarticular  fibro-cartilage  is  an  ovoid  plate  placed  between 
the  two  bones.  It  is  supported  in  its  position  by  a  more  or  less 
perfect  circumferential  attachment  to  the  common  capsule,  the 
external  lateral  ligament,  and  to  the  tendon  of  the  external  pterygoid 
muscle  :  below,  its  face  is  concave,  corresponding  with  the  convexity 


76  ORAL  DISEASES  AND  SURGERY. 

of  the  condyle ;  above,  it  is  concave  in  front,  convex  behind,  cor- 
responding with  the  glenoid  cavity  proper,  and  the  eminentia  articu- 
laris.  In  composition  the  circumference  is  markedly  fibrous,  shading 
off  to  a  cartilaginous  centre,  frequently  quite  soft,  and  sometimes 
perforated. 

The  synovial  membranes,  placed,  as  seen  in  the  view,  one  above, 
the  other  below  the  interarticular  fibro-cartilage,  are  the  ordinary 
lubricating  membranes  of  closed  cavities  ;  they  may  very  well  be 
likened  to  two  simple  bags,  with  parietal  attached  faces.  These 
bags  secrete  the  synovia,  a  fluid  which  looks  not  unlike  the  white 
of  an  Qor^,  but  which  is  much  more  oily  and  resistive  in  its  nature. 

From  the  spinous  process,  seen  on  the  great  wing  of  the  sphenoid 
bone,  a  ligament,  the  internal  lateral,  descends  to  be  attached  to  the 
inner  face  of  the  ramus.  Behind,  from  the  styloid  process  of  the 
OS  temporis,  a  second,  the  stylo-maxillary,  passes  to  be  inserted  just 
above  the  angle. 

The  external  lateral  ligament  is  a  short,  soihewhat  triangular- 
shaped  band  of  fibrous  tissue,  having  origin  from  the  zygoma;  pass- 
ing obliquely  downward  and  backward,  and  inserted  about  the  neck 
of  the  condyle ;  just  below  the  head,  it  lies  in  contact  with  the  lateral 
aspect  of  the  interarticular  fibro-cartilage,  and  really  assists  in  form- 
ing, or  at  least  in  thickening,  the  common  capsule.  Externally,  it  is 
quite  superficial,  being  covered  only  by  the  integuments,  except  in 
instances  where  the  upper  border  of  the  parotid  gland  spreads  over 
it.  The  importance  of  the  character  of  this  articulation  renders 
necessary  its  careful  study  by  personal  dissection. 


CHAPTER    III. 


FIFTH     PAIR     OF     NERVES. 


Fig.  31. — Section  of  Head,  exhibiting  at  a  Common  View  the  Distri- 
bution OF  THE  Fifth  Pair  op  Nerves  to  the  Teeth. 


The  fifth  is  an  encephalic  nerve, — that  is,  coming  off  from  that 
portion  of  the  cerebro-spinal  centre  lying  within  the  cranium.  It  is 
called  the  fifth,  because  this  is  the  order  of  its  emergence ;  also  tri- 
facial, because,  while  within  the  cranium,  it  divides  into  thi-ee  por- 
tions, which  portions,  in  their  divisions  and  subdivisions,  are 
distributed  respectively  to  the  superior,  middle,  and  inferior  portions 
of  the  facial  region;  also  "trigeminus,"  a  name  derived  from  tri, 
three,  and  geminus,  twin,  or  double,  signifying  literally  three  double, 
triple,  referring  to  its  threefold  divisions. 

(77) 


78 


OKAL  DISEASES  AND  SURGERY. 


The  fifth,  trifacial  or  trigeminus,  is  first  discovered  as  a  number 
of  filaments,  of  which  there  are  two  distinct  sets,  coming  off  from 
the  sides  of  the  pons  Yarolii ;  this  is  called  its  superficial  origin. 
The  deep,  or  true  origin,  can  be  traced  into  the  substance  of  the  pons 
as  far  as  the  lateral  tract  of  the  medulla  oblongata.  These  filaments 
of  origin  are  called  the  roots  of  the  nerve,  and,  being  twofold,  afford 

Fig.  32. — Trifacial  Division  axd  Ganglia. 


Trifaciai  nerve,  the  upper  part  uf  tli"  orliit  ami  Ifiiipcral  fo-isa  removed.  1,  semilunar 
ganglion ;  2,  ophthalmic  nerve  ;  3,  lachrymal  nerve ;  4,  frontal  nerve ;  5,  6,  its  two  prin- 
cipal hranches  ;  7,  a  branch  passing  from  the  orl)ital  above  the  pulley  of  the  superior 
oblique  muscle;  8,  nasal  nerve;  9,  its  external  nasal  brancli ;  10,  course  of  the  internal 
nasal  nerve  from  the  orbit  into  the  cranium  and  nose ;  11, 12,  13,  temporal  branches  of 
the  inferior  maxillary  nerve;  14,  commencement  of  the  auriculo-temporal  nerve;  15, 
greater  petrosal  nerve.  I,  olfactory  nerve;  II,  optic  nerves;  III,  oculo-motor  nerve; 
lA',  pathetic  nerve  to  the  superior  oblique  muscle  of  the  eye;  V,  trifacial  nerve;  its 
small  root  visible  beneath  the  cut  end  of  the  large  root,  which  forms  the  semilunar  gan- 
glion dividing  into  the  ophthalmic,  superior,  and  inferior  maxillary  nerves;  A'l,  abdu- 
cent nerve;  A'll,  facial,  included  in  a  groove  of  the  auditory  nerve,  A'lII,  both  entering 
the  auditory  meatus;  IX,  glosso-pharyngeal,  X,  pneumogastric,  and  XI,  accessory  nerves 
emerging  at  the  jugular  foramen;  XII,  hypoglossal  nerve. 


the  likeness  which  exists  between  this  particular  encephalic  nerve 
and  the  nerves  of  the  spinal  cord. 

The  fifth  nerve  is  peculiar  in  being  both  compound  and  special : 


THE  FIFTH  PAIR    OF  NERVES.  79 

that  is  to  say,  it  supplies  parts  with  filaments  of  sensation,  with  fila- 
ments of  motion,  and  through  one  of  its  branches,  called  the  "gusta- 
tory," with  filaments  which  pertain  to  the  sense  of  taste.  It  is  the 
great  sensitive  nerve  of  the  head  and  face  ;  the  nerve  of  motion  to 
the  muscles  of  mastication  ;  the  nerve  of  the  sense  of  taste  to  the 
anterior  part  of  the  tongue.   (See  Function  of  Nerve.) 

Immediately  on  the  emergence  of  the  roots  from  the  points  of 
their  superficial  origin,  they  pass  through  a  slit-like  opening  in  the 
dura  mater  at  the  apex  of  the  petrous  portion  of  the  temporal  bone. 
Here  the  larger  root,  called  the  sensor,  enters  a  ganglion,  lying  in  a 
fossa  on  the  anterior  face  of  this  triangular  apex,  the  Gasserian  or 
semilunar. 

The  ganglion  of  Gasser  is  a  small  reddish-gray  semilunar  knot 
enveloping  apparently  the  great  or  post»i'ior  root  of  the  fifth  nerve 
as  it  passes  over  the  temporal  apex ;  its  size  is  about  equal  to  that 
of  an  ordinary  buckshot,  although,  from  its  flattened  and  crescentic 
form,  the  measurement  from  tip  to  tip  of  its  horns  would  surpass 
somewhat  the  diameter  of  such  a  shot.  The  convex  face  of  the  gan- 
glion looks  forward. 

On  emerging  from  this  ganglion,  the  posterior  root  is  found 
divided  into  three  cords, — the  three  primary  divisions  of  the  sensi- 
tive portion.  The  first  of  these  cords  constitutes  what  is  called  the 
ophthalmic  nerve,  or  the  ophthalmic  portion  or  division  of  the  fifth 
nerve.  The  second  cord  is  the  superior  maxillary  nerve,  or  superior 
maxillary  division  of  the  fifth.  The  third  is  the  inferior  maxillary 
nerve. 

The  first  of  these  nerves  has  its  distribution  over  the  orbito-frontal 
region. 

The  second  has  its  distribution  over  the  superior  maxillary 
region. 

The  third  associates  with  the  lesser  or  motor  root,  which  root 
first  connects  with  it  at  the  base  of  the  skull,  and  has  its  distribution 
over  the  inferior  maxillary  region. 

OPHTHALMIC   NEKVE. 

This  division  of  the  fifth  passes  from  the  Gasserian  ganglion  along 
the  outer  wall  of  the  cavernous  sinus,  and  enters  the  orbit  through 
the  sphenoidal  fissure ;  before  entering  this,  however,  it  breaks  up 
into  three  branches.  These  branches  supply  the  eyeball,  the  lach- 
rymal gland,  the  mucous  lining  of  the  nose,  and  the  muscles  and 
the  integument  of  the  forehead.    They  are  called  frontal,  lachrymal, 


80  ORAL  DISEASES  AND  SURGERY. 

nasal.  The  ophthalmic  is  the  smallest  of  the  three  divisions  of  the 
fifth.  It  is  a  flattened  band  not  more  than  an  inch  in  length,  receiv- 
ing, before  breaking  up  into  its  terminal  branches,  filaments  from 
the  carotid  plexus  of  the  sympathetic,  and  giving  off  two  or  more 
filaments,  which,  with  a  branch  from  the  fourth  nerve,  pass  between 
the  layers  of  the  tentorium. 

The  Frontal  Branch  is  the  largest  of  the  divisions  of  the  ophthal- 
mic, and  is  commonly  regarded  as  the  continuation  of  the  nerve.  In 
the  orbit  it  lies  above  the  levator  palpebrss  muscle,  between  it  and 
the  periosteum,  dividing  about  midway  of  the  cavity  into  two 
branches, — supratrochlear  and  supraorbital. 

The  supratrochlear  branch  passes  inward  to  the  pulley  of  the 
superior  oblique  muscle,  giving  off  here  descending  filaments  which 
anastomose  with  similar  trochlear  filaments  from  the  nasal  nerve. 
A  second  or  terminal  branch  passes  from  the  orbit  between  the 
superior  oblique  and  supraorbital  foramen,  ascends  behind  the  cor- 
rugator  supercilii  and  occipito-frontalis  muscles,  to  both  of  which  it 
distributes  filaments,  and  is  finally  lost  in  the  integument  of  the 
forehead. 

The  supraorbital  branch  or  division  of  the  frontal  passes  forward 
until  it  reaches  the  supraorbital  foramen,  when  it  passes  out  unto 
the  forehead.  In  this  situation  it  gives  off  a  number  of  filaments  to 
the  upper  eyelid,  called  palpebral.  In  its  distribution  over  the  fore- 
head, it  sends  branches  to  the  orbicularis  palpebrarum,  occipito- 
frontalis,  and  corrugator  supercilii  muscles,  anastomosing  in  the 
first-named  muscles  with  filaments  of  the  facial  nerve.  Other  two 
sets  of  terminal  filaments  supply,  the  first,  the  periosteum  covering 
the  frontal  and  parietal  bones ;  the  second,  the  integument,  as  far 
back  as  the  occiput. 

The  Lachrymal. — This  is  the  smallest  of  the  three  divisions  of 
the  ophthalmic.  It  is  almost  always  accompanied  by  filaments  from 
the  fourth  nerve.  In  the  orbit  it  connects  itself  with  the  orbital 
branch  of  the  second  or  superior  maxillary  division  of  the  fifth 
nerve.  Its  distribution  is  to  the  lachrymal  gland,  the  conjunctiva, 
and  the  integument  of  the  upper  eyelid,  in  which  last  situation  it 
joins  with  filaments  of  the  facial  nerve. 

The  Naxal. — This  division  is  intermediate  in  size  between  the 
frontal  and  lachrymal.  Entering  the  cavity  of  the  orbit  between  the 
two  heads  of  the  external  rectus,  it  passes  directly  across  the  optic 
nerve  to  the  anterior  of  the  ethmoidal  foramina;  through  this  fora- 
men it  passes  into  the  cavity  of  the  cranium,  where  it  traverses  the 


THE  FIFTH  PAIR   OF  NERVES.  81 

shallow  groove  on  the  front  of  the  cribriform  plate  of  the  ethmoidal 
bone,  until  arriving  at  the  nasal  slit  it  passes  directly  downward 
into  the  nose,  terminating  in  two  branches.  Of  these  two  branches, 
the  external  descends  on  the  inner  surface  of  the  nasal  bone,  supply- 
ing the  mucous  membrane  of  its  neighborhood  ;  leaving  the  cavity 
at  the  juncture  of  the  bone  with  the  lateral  cartilage,  it  passes,  on 
the  external  part  of  the  nose,  down  to  supply  the  integument  of  the 
lips,  and  join  with  the  facial  nerve.  The  second  branch,  the  internal, 
supplies  the  mucous  membrane  about  the  front  of  the  septum. 

In  the  orbital  cavity  are  given  off  three  branches  from  the  nasal 
— the  ganglionic,  ciliary,  and  infratrochlear. 

The  ganglionic  is  a  slender  cord,  about  half  an  inch  in  length, 
which  is  the  sensor  filament  to  the  orbital  or  ophthalmic  ganglion. 
(See  Ganglia.) 

The  ciliary  separates  into  branchlets,  called  long  ciliary,  to  distin- 
guish them  from  certain  shorter  branches,  called  also  ciliary,  given 
off  from  the  ophthalmic  ganglion.  These  branches  are  two  or  three 
in  number,  and,  in  association  with  the  short  ciliary,  pierce  the  pos- 
terior face  of  the  sclerotic,  and,  passing  between  this  coat  and  the 
choroid,  are  distributed  to  the  ciliary  muscle  and  iris. 

The  infratrochlear  branch  is  given  off  just  as  the  main  portion 
passes  into  the  ethmoid  foramen,  joining  beneath  the  pulley  of  the 
superior  oblique  muscle,  with  a  filament  of  the  supratrochlear  nerve  ; 
this  branch  continues  to  the  inner  angle  of  the  eye,  where  it  is  dis- 
tributed to  the  orbicular  muscle,  the  integument  of  the  eyelid,  and 
side  of  the  nose,  to  the  conjunctiva,  caruncula  lachrymalis  and  lach- 
rymal sac. 

RecapiluJation. — The  ophthalmic  or  first  division  of  the  fifth 
nerve  supplies  the  tentorium,  lachrymal  gland,  caruncula  lachry- 
malis, lachrymal  sac,  ciliary  muscle  and  iris,  muscles  of  eyelid  and 
forehead,  integument  of  forehead  and  nose,  mucous  membrane  of 
eye  and  nose,  and  pericranium  of  frontal  and  parietal  regions. 

SUPEKIOK   MAXILLARY  NEEVE. 

This  nerve  or  division  arises,  as  a  flattened  band,  from. the  middle 
of  the  Gasserian  ganglion.  It  passes  forward  over  the  greater  wing 
of  the  sphenoid  bone,  until,  reaching  the  foramen  rotundum,  it  leaves 
the  cranium,  and  presents  itself  in  the  spheno-maxillary  fossa ;  from 
this  fossa  it  passes  to  the  orbital  cavity,  through  the  spheno-maxil- 
lary fissure,  where,  being  lodged  in  the  infraorbital  canal,  it  con- 
tinues forward  to  the  points  of  its  ultimate  distribution. 

6 


82 


ORAL  DISEASES  AND  SURGERY. 


Branches  of  Distribution. — 1.  In  the  Spheno-maxillay-y  Fossa. 
Three, — the  orbital,  the  ganglionic,  the  posterior  dental. 

The  orbital  enters,  with  the  main  branch  of  the  nerve,  the  orbital 
cavity,  and  divides  into  two  branches,  temporal  and  malar.  The 
temporal  branch  passes  from  the  orbit  through  a  foramen  in  the 
malar  bone,  and  enters  the  temporal  fossa ;  it  here  perforates  the 
temporal  muscle  and  fascia,  and  is  distributed  to  the  integument 


Superior  Maxillary  Nerve. 


The  external  ■wall  of  the  left  orbit  and  of  the  superior  maxillary  bone  removed. 

I,  superior  inaxilliiry  iii-rve  in  its  course  through  thn  infraorliilul  c.inal ;  2,  3,  posterior 
dental  nerves;  4.  anterior  dental  nerve;  5,  anastomosis  lietween  the  dental  nerves;  6, 
spheno-palatine  ganglion;  the  branch  from  the  superior  maxillary  nerve  above  is  the  i 
commencement  of  the  temporo-malar  nerve;  7,  pterygoid  nerve;  8,  greater  petrosal 
nerve  joining  the  facial  nerve;  9,  deep  petrous  nerve  joining  the  carotid  plexus  of  Hio 
sympathetic  ;  10,  abducent  nerve  with  its  communicating  branches  of  the  latter  plexus ; 

II,  superior  cei-vical  ganglion;  12,  ascending  branches  to  the  carotid  plexus;  13,  facial 
nerve;  14,  glosso-pharyngeal  nerve;  15,  the  tympanic  nerve;  16,  branch  to  the  carotid 
plexus;  17,18,19,  branches  to  the  round  and  oval  windows  and  Eustachian  tube;  20, 
branch  to  the  smaller  petrosal  nerve,  '21. 

covering  the  side  of  the  head,  and  associates  with  the  facial  nerve, 
also  with  an  ascending  branch,  auriculo-temporal,  of  the  inferior 
maxillary.  The  malar  branch  leaves  the  orbit  also  through  a  foramen 
in  the  malar  bone,  perforates  the  orbicularis  palpebrarum  muscle, 
and  joins  with  a  branch  of  the  facial. 

The  ganglionic  divides  into  two  branches,  which  drop  directly 
down  into  the  spheno-palatine,  or  Meckel's  ganglion  ;  hence  they  are 
commonly  known  as  the  spheno-palatine  branches. 

The  posterior  dental  arises  from  the  trunk  just  as  it  enters  the 
orbit;  it  immediately  breaks  up  into  an  anterior  and  a  posterior 
portion.  The  first  supplies  the  gums  and  buccinator  muscle ;  the 
second  pierces  the  tuberosity  of  the  maxillary  bone,  and,  after  form- 


THE  FIFTH  PAIR    OF  NERVES.  83 

\ng  a  minute  plexus  above  the  alveolus,  distributes  filaments  to  each 
of  the  posterior  teeth  ;  its  termination  is  lost  in  a  union  with  the 
anterior  dental  nerve. 

2.  In  the  Infraorbital  Canal. — One, — the  anterior  dental.  This 
branch  is  given  off  about  midway  of  the  canal.  It  enters  a  second 
canal  existing  on  the  anterior  face  of  the  maxillary  sinus,  and  curv- 
ing backward,  associates  itself,  as  above  alluded  to,  with  the  pos- 
terior dental ;  from  the  curve  are  given  off  filaments  to  the  anterior 
teeth, — incisors,  canines,  and  bicuspidati. 

3.  On  the  Face. — Three, — palpebral,  uasal,  labial.  These  are  the 
terminal  filaments,  the  division  occurring  as  the  nerve  issues  from 
the  infra()rl)ital  foramen.  The  palpebral  filaments  pass  up  to  the 
supply  of  the  orbicularis  palpebrarum  muscle  and  the  integument 
and  conjunctiva  of  the  lower  eyelid  ;  at  the  outer  angle  of  the  orbit 
they  associate  with  the  malar  bratich  of  the  orbital  and  filaments  of 
the  facial  nerve.  The  nasal  filaments  pass  across  the  nose,  supply- 
ing the  muscles  and  integument  of  this  region  ;  they  usually  join  at 
the  tip  with  the  nasal  branch  of  the  ophthalmic.  The  labial  fila- 
ments pass  downward  beneath  the  levator  labii  superioris,  and  are 
distributed  to  the  muscles  and  integument  of  the  upper  lip,  to  the 
mucous  menibrane  of  the  mouth,  and  to  the  labial  glands.  The 
intricate  plexus  situated  in  the  canine  fossa  is  formed  of  filaments 
from  the  facial  nerve  associating  with  twigs  of  the  trimaxillary 
division. 

Recapitulation. — The  superior  maxillary  nerve,  or  second  division 
of  the  fifth,  supplies  the  integument  on  the  side  of  the  head,  Meckel's 
ganglion  with  its  sensor  filaments,  the  teeth,  the  antrum,  orbicularis 
palpebrarum  muscle,  integument  and  conjunctiva  of  lower  eyelid, 
muscle  and  integument  of  nose,  muscles,  integument,  and  mucous 
membrane  of  superior  lip,  and  labial  glands. 

INFERIOR  3IAXILLARY  NERVE. 

This  nerve  or  division  is  the  largest  of  the  three,  and  constitutes, 
justly  speaking,  the  only  portion  of  the  fifth  nerve  compound  in 
character  The  sensor  portion  is  the  third  of  the  cords  emerging 
from  the  Gasserian  ganglion ;  the  motor  portion  is  that  lesser  root 
alluded  to  as  coming  off  from  the  pons  Varolii ;  the  sensor  cord  falls 
quickly  into  the  oval  foramen  of  the  sphenoid  bone,  through  which 
it  passes  from  the  cranium.  The  motor  cord,  which  has  passed 
forward  beneath  the  Gasserian  ganglion,  unites  with  the  sensor  just 


84 


ORAL   DISEASES  AND  SURGERY. 


as  it  emerges  from  this  foramen.  Here  then  is  made,  by  this  union, 
a  single  cord,  the  perfected  or  compound  inferior  maxillary  nerve — 
a  nerve  made  up  of  filaments  of  motion  and  filaments  of  sensation. 
At  the  point  of  juncture  of  these  two  cords  is  found  a  little  ganglion, 
the  otic.  (See  Ganglia.) 

Fig.  34  — Txferior  ^Faxillaky  Nerve. 


Distribution  of  the  iNFtRioR  .m.\xillakv  .nekve.  1,  iiiii!<ciilstr  biaiich  to  the  niasseter 
miisfle;  2.  5,  7,  branches  to  the  tempural  niu8cle ;  3,  branch  to  the  buccinator,  anasto- 
niosing  with  one  from  tlie  facial  at  4 ;  6,  external  pterygoiil  muscle;  8,  auriculo-temporal 
nerve;  9,  branches  to  the  temple  ;  10,  branches  to  the  ear;  11,  its  ana-stoniosis  with  the 
facial;  12,  lingual  nerve;  13,  branch  to  the  niylo-hyoid  muscle  from  the  inferior  dental 
nerve,  14;  15,  branches  to  the  teeth ;  16,  terminal  branches  to  the  lower  lip  and  chin. 

Immediately  beneath  the  base  of  the  skull,  this  compound  inferior 
maxillary  nerve  divides  into  two  branches, — anterior  and  posterior. 
Into  the  anterior  branch  pass  most  of  the  motor  filaments. 

The  anterior  branch  breaks  up  into  five  divisions,  and  is  dis- 
tributed to  the  muscles  of  mastication.  These  divisions  or  branches 
receive  names  from  the  parts  supplied  by  them  ;  they  are  the  mas- 
seteric, buccal,  deep  temporal,  and  pterygoid. 


THE  FIFTH  PAIR   OF  NERVES.  85 

The  posterior  branch  is  the  larger  of  the  two  divisions ;  it  sub- 
divides into  three  parts.  These  supply  the  inferior  teeth,  tongue, 
and  auriculo-teniporal  region.  Hence  the  branches  are  named  infe- 
rior dental,  lingual,  and  auriculo-temporal. 

Divisions  of  Anterior  Branch.  —  Masseteric.  —  This  branch 
runs  across  the  sigmoid  notch  of  the  inferior  maxillary  bone,  enters 
the  substance  of  the  masseter  muscle,  and  is  distributed  in  it.  In 
crossing  the  notch  it  occasionally  gives  off  a  filament  to  the  articula- 
tion. 

Deep  Temporal  Branches. — The.se  are  two  in  number.  They  pass 
under  the  temporal  muscle,  and  supply  its  deep  surface. 

Buccal. — This  branch  pierces  the  external  pterygoid  muscle, 
passes  beneath  the  coronoid  process  of  the  jaw,  pierces  the  fibres  of 
the  temporal  muscle,  and,  reaching  the  buccinator,  divides  upon  it 
into  a  superior  and  inferior  branch.  The  superior  supplies  the  upper 
part  of  the  muscle  and  the  integument;  the  inferior,  the  lower  part 
of  the  muscle  and  its  lining  mucous  membrane. 

Pterygoid  Branches. — Two  in  number, — one  supph'ing  each 
pterygoid  muscle. 

Divisions  of  Posterior  Branch. — Auricula- Temjjoral. — This 
branch  passes  out  to  the  inner  side  of  the  temporo-maxillary  articu- 
lation, turns  upward  in  company  with  the  temporal  artery,  and,  on 
emerging  with  this  vessel  from  beneath  the  parotid  gland,  divid.es 
into  two  branches.  The  posterior  of  the  two  supplies  the  attraheris 
auriculae,  the  pinna,  and  the  neighboring  integument.  The  anterior 
passes  upward  with  the  terminal  branches  of  the  artery,  and  is  dis-. 
tributed  to  the  temporal  integument.  Branches  of  communication 
exist  between  the  auriculo-temporal  nerve,  the  facial,  and  the  otic 
ganglion.  The  articulation,  the  parotid  gland,  and  the  external 
auditory  meatus  receive  nerve  endowment  from  the  auriculo-tem- 
poral. 

Lingual  or  Gustatory. — This  branch  is  a  nerve  of  special  sense, 
presiding  in  part  over  the  function  of  taste;  its  terminal  filaments, 
as  might  be  inferred,  are  distributed  extensively  to  the  papillae  and 
mucous  membrane  of  the  tongue.  Of  the  three  sets  of  papillae,  the 
filiform  and  fungiform,  or  those  situated  on  the  anterior  two  thirds 
of  the  organ,  receive  the  principal  supply,  the  posterior  or  great 
papillae  being  supplied  from  the  glosso-pharyngeal.  On  this  account 
it  was  deduced  that  the  gustatory  presided  over  taste  only  as  the 
anterior  two-thirds  of  the  tongue  was  concerned ;  and  this  infer- 
ence has  been  abundantly  borne  out  by  vivisection.     (See  Todd  and 


86  ORAL  DISEASES  AND   SURGERY. 

Bowman's  Phj^siology,  pages  385  to  390.)  In  the  dissection,  the 
gustatory  branch  is  seen  coming  off  just  opposite  the  sigmoid  notch. 
In  company  with  the  inferior  dental  nerve,  or  branch,  it  passes  down 
along  the  inner  side  of  the  ramus,  until,  leaving  the  dental  somewhat 
al)ove  the  posterior  dental  canal,  it  crosses  obliquely  to  the  side  of 
the  tongue,  along  which  it  pursues  its  way  to  its  points  of  final 
termination,  anastomosing  at  the  tip  of  the  organ  with  filaments  of 
the  hypoglossal.  In  its  course  it  lies  first  beneath  the  external  ptery- 
goid muscle,  crosses  the  internal  pterygoid,  rests  upon  the  superior 
constrictor  of  the  pharynx,  and  pas.ses  over  Wharton's  duct,  where 
it  reaches  the  apex  of  the  tongue.  In  its  course,  branches  of  commu- 
nication are  given  off  to  the  submaxillary  ganglion  and  the  hypo- 
glossal nerve. 

Inferior  Dental  Nerve  or  Branch. — This  is  the  largest  of  the 
three  divisions  of  the  inferior  maxillary  nerve.  Between  its  point 
of  origin  and  entrance  into  the  dental  canal,  it  gives  off  a  branch, 
the  mylo-hyoid,  distributed  to  the  niylo-hyoid  and  anterior  belly  of 
the  digastric  muscles.  The  main  portion,  after  entering  the  poste- 
rior foramen  of  the  dental  canal,  pursues  its  way  beneath  the  teeth, 
giving,  in  its  course,  filaments  to  all  these  organs,  terminating  finally 
in  a  branch,  the  mental,  which  passes  from  the  canal  at  the  mental 
foramen,  and  has  its  distribution  in  the  muscular  and  cutaneous 
substance  of  the  inferior  lip. 

Recapitulation. — The  inferior  maxillary  nerve,  or  third  division 
of  the  fifth,  supplies  the  muscles  of  mastication,  the  auriculo-temporal 
region,  the  anterior  two-thirds  of  the  tongue,  the  mylo-hyoid  and 
digastric  muscles,  the  inferior  teeth,  and  the  muscles  and  skin  of  the 
lower  lip. 

GANGLIA  OF  THE  FIFTH  PAIR  OF  NERVES. 

Associated  with  the  fifth  nerve  are  six  ganglia :  they  are  called 
Gasserian;  ophthalmic,  lenticular,  or  ciliary;  Meckel's,  or  spheno- 
palatine; naso-palatine;  or  ganglion  of  Cloquet;  otic;  submaxil- 
lar v. 

Ganglion  of  Gasser. — This  ganglion,  called  as  frequently  the 
semilunar,  from  its  shape,  is  found  lying  in  a  slight  depression  on 
the  anterior  face,  near  the  apex  of  the  petrous  portion  of  the  tem- 
poral bone.  It  receives  the  posterior  or  sensor  cord  of  the  fifth 
nerve,  and  transmits  it  divided  into  three  parts.  The  ganglion 
receives  filaments  from  the  carotid  plexus  of  the  sympathetic,  and 


THE  FIFTH  PAIR   OF  NERVES. 


87 


gives  off  filaments  to  the  tentorium  cerebelli,  and  to  the  dura  mater 
of  the  middle  fossa  of  the  cranium. 

Ophthalmic,  Lenticular,  or  Ciliary  Ganglion. — This  ganglion, 
as  implied  in  its  name,  is  found  in  the  cavity  of  the  orbit.  It  is  a 
small,  quadrangular,  flattened  body,  not  larger,  generally,  than  the 
ordinary  pin-head.    It  is  situated  between  the  external  rectus  muscle 

Fig  35. — Ophthalmic  Ganglion — the  Outer  Part  of  the  Eight  Orbit 

Kemoved. 


«    7         10 

1,  optic  nerve;  2,  oculo-motor  nerve;  3,  branch  to  the  superior  straight  and  oblique 
muscles;  4,  branch  to  the  inferior  oblique  muscle;  6,  abducent  nerve  to  the  external 
straight  muscle  ;  6,  trifacial  nerve,  its  ganglion  and  three  principal  branches  ;  7,  ophthal- 
mic nerve;  8,  nasal  nerve;  9,  ophthalmic  ganglion;  10,  its  communicating  branch  with 
the  oculo-motor  nerve;  11,  do.  with  the  ophthalmic  nerve;  12,  do.  with  the  carotid 
plexus  of  the  sympathetic  ;  13,  the  ciliary  nerves  ;  14,  frontal  nerve. 

and  optic  nerve,  well  enveloped  in  the  mass  of  fat  found  occupying 
this  portion  of  the  cavity.  Its  branches  of  communication  are 
derived,  the  first,  or  sensor,  from  the  nasal  ;  the  second,  or  motor, 
from  the  third  nerve  ;  the  third,  or  sympathetic,  from  the  cavernous 
plexus.  Its  branches  of  distribution  are  the  short  ciliary  nerves. 
These  nerves,  ten  or  twelve  in  number,  arise  from  the  anterior  face 
of  the  ganglion,  being  connected,  as  two  sets  of  filaments,  with  the 
superior  and  inferior  angles.  The  two  sets  pass  forward,  one  being 
above,  the  other  below  the  optic  nerve,  until,  reaching  the  sclerotic 
coat  of  the  eye,  they  penetrate  this  organ,  and  ai-e  distributed  to  the 
ciliary  muscle  and  iris. 

MeckeVs  Ganglion — Spheno-Palatine. — This  is  the  largest  and 
most  extensively  connected  of  the  cranial  ganglia.  Its  position  is 
in  the  spheno-maxillary  fossa,  immediately  in  front  of  the  vidian 
foramen.  In  shape  it  is  triangular,  and  in  color  reddish-gray.  Its 
branches  of  communication  are  derived,  the  first,  or  sensor,  from  the 
superior  maxillary  nerve,  which,  as  has  been  seen,  gives  to  it  two 


88 


ORAL  DISEASES  AND  SURGERY. 


filaments  while  crossing  the  fossa.  The  second,  or  motor,  is  derived 
from  the  facial  nerve,  or  rather  fi-om  the  intumescentia  gangliformis 
of  that  nerve.  This  branch  is  known  as  the  great  petrosal  nerve;  it 
emerges  from  the  Fallopian  canal  through  the  hiatus  Fallopii,  passes 
along  the  groove  leading  from  this  foramen,  until,  reaching  the  foramen 

Fig,  36. — View  of  the  Spheno-Palatine  GAxoLrox,  the  Outer  Wall 
OF  THE  Left  Nasal  Cavity,  and  the  Olfactory  Nerve. 


1,  olfactory  nerve;  2,  nasal  branch  of  the  ophthalmic  nerve;  3,  spheno-palatine  gan- 
glion; 4,  5,  6,  palatine  nerves;  7,  branch  to  the  nose;  8,  nasal  nerve  to  the  outer  wall  of 
the  nose;  9,  do.  to  the  inner  wall;  10,  pterj'goid  nerve;  11,  facial  nerve;  12,  deep  petrous 
nerve  joining  the  carotid  ple.xus;  13,  the  other  branch  of  the  pterygoid  is  the  larger 
petrosal  nerve,  which  joins  the  facial. 

lacerum  basis  cranii,  it  pierces  the  cartilaginous  substance,  filling  up 
this  osseous  break,  and  entering  the  vidian  canal,  associated  with 
the  carotid  nerve,  passes  forward  under  the  name  of  vidian  to  the 
ganglion.  The  third,  or  sympathetic,  is  derived  from  the  carotid 
plexus  through  the  vidian. 

The  branches  of  distribution  from  this  ganglion  are  numerous, 
and  supply  a  portion  of  the  orbital  periosteum,  the  nares,  the  hard 
and  soft  palates,  the  half  arches,  the  tonsil,  the  pharynx,  etc. 

The  ascending  branches,  two  or  three  in  number,  enter  the  orbit 
through  the  spheno-maxillary  fissure,  and  supply  the  periosteum. 

The  descending,  called  palatine  branches,  are  three  in  number; 
the  anterior  of  these,  or  large  palatine  nerve,  descends  through  the 
posterior  palatine  canal,  passes  along  the  groove  on  the  hard  palate, 
and  is  distributed  to  the  gums,  the  mucous  membrane,  and  palatine 
glands,  anastomosing  back  of  the  incisor  teeth  with  the  naso-pala- 


THE  FIFTH  PAIR    OF  NERVES.  89 

tine  nerve;  while  in  the  palatine  canal,  filaments  are  given  off  which 
pass  to  the  middle  and  inferior  turbinated  bones. 

The  middle  branch,  called  external  palatine  nerve,  descends  through 
the  same  canal  as  the  preceding;  it  distributes  its  filaments  to  the 
soft  palate,  to  the  uvula,  and  the  tonsil. 

The  posterior,  called  small  palatine  nerve,  descends  through  the 
accessory  palatine  canal,  and  emerges  back  of  the  posterior  palatine 
foramen.  It  is  distributed  to  the  levator  palati  muscle,  to  the  soft 
palate,  tonsil,  and  uvula. 

Coming  off  from  the  internal  surface  are  two  sets  of  branches; 
these  are  called  superior  nasal  and  naso-palatine. 

The  superior  nasal,  four  or  five  in  number,  enter  the  nasal  fossa  by 
the  spheno-palatine  foramen;  they  supply  the  mucous  membrane  of 
the  superior  portion  of  the  fossa. 

The  naso-palatine  enters  the  fossa  with  the  other  nasal  nerves, 
passes  across  the  roof  of  the  nose,  until,  reaching  the  septum,  it  de- 
scends between  the  periosteum  and  mucous  membrane  to  the  ante- 
rior palatine  foramen  ;  passing  through  this  canal,  it  unites  with  its 
fellow  of  the  opposite  side,  and  distributes  its  filaments  to  the  mu- 
cous membrane  about  the  incisive  fossa. 

Naso-Palatine  Ganglion,  or  Ganglion  of  Cloquet. — This  is  simply 
the  small  swelling  situated  in  the  incisive  fossa,  the  result  appar- 
ently of  the  union  of  the  naso-palatine  nerves.  The  very  name  of 
ganglion  is  denied  it  by  most  writers. 

Otic  Ganglion. — This  is  an  oval  flattened  body,  of  small  size, 
lying  on  the  sensor  portion  of  the  inferior  maxillary  nerve,  imme- 
diately beneath  the  oval  foramen.  Its  branches  of  communication 
are:  by  sensor  filaments,  with  the  auriculo-temporal  nerve,  by  motor 
with  the  inferior  maxillary  nerve,  and  with  the  sympathetic  by  the 
plexus  surrounding  the  middle  meningeal  artery.  Branches  of  com- 
munication also  exist  with  the  glosso-pharyngeal,  and  through  the 
medium  of  the  les.ser  petrosal  with  the  facial  nerve. 

The  branches  of  distribution  are  two  in  number:  one  to  the  ten- 
sor tympani,  and  one  to  the  tensor  palati  muscles. 

Submaxillary  Ganglion. — This  is  a  small-sized  circular  ganglion, 
situated  upon  the  submaxillary  gland.  It  is  connected,  through 
communicating  branches,  with  the  gustatory  nerve,  sensor;  with  the 
facial,  through  the  medium  of  the  chorda  tympani,  motor  ;  and  with 
the  sympathetic  by  filaments  from  the  plexus  of  the  nervi  moUes. 

The  tji'anches  of  distribution  are  five  or  six  in  number ;  they  arise 
from  the  lower  part  of  the  ganglion,  and  supply  the  duct  of  the  gland 
and  mucous  membrane  of  the  floor  of  the  mouth. 


90  ORAL  DISEASES  AND   SURGERY. 


FUNCTION  OF  THE  FIFTH  NERVE.* 

"  The  determination  of  the  functions  of  the  roots  of  spinal  nerves 
has  afforded  the  clue  to  that  of  the  functions  of  the  roots  of  the  fifth 
nerve.  The  analogy  of  the  smaller  root  of  the  fifth  with  the  ante- 
rior spinal  root,  and  of  the  larger  one  with  the  posterior  spinal  root, 
has  long  been  admitted  by  anatomists.  Hence  an  analogy  of  func- 
tion must  be  admitted,  and  the  former  must  be  viewed  as  consisting 
of  motor  fibres,  the  latter  of  sensitive  ones;  and  by  tracing  each  of 
the  three  great  divisions  of  the  nerve,  we  may  determine  its  func- 
tion by  its  constitution,  according  as  it  derives  its  fibres  from  either 
root  or  from  both.  The  ophthalmic  and  superior  maxillary  are  com- 
posed of  fibres  derived  exclusively  from  the  larger  root;  they  are, 
therefore,  sensitive  nerves.  The  inferior  maxillary  consists  of  fibres 
derived  from  both  roots,  and  consequently  is  both  motor  and  sensi- 
tive. Sir  C.  Bell,  in  his  original  exposition  of  the  functions  of  this 
nerve,  fell  into  error  from  having  neglected  to  avail  himself  of  this 
method  of  analyzing  the  constitution  of  each  of  its  three  divisions, 
from  which  he  would  have  seen  that  it  is  the  inferior  maxillary  alone 
which  derives  its  fibres  from  both  roots,  and  which  perfectly  resem- 
bles a  spinal  nerve  in  constitution. 

"  The  distribution  of  the  three  divisions  of  the  fifth  nerve  confirms 
most  amply  the  view  of  its  physiology  suggested  by  the  anatomy  of 
its  origin.  The  ophthalmic  and  superior  maxillary  are  distributed 
entirely  to  sentient  surfaces,  or  anastomose  with  motor  nerves  (the 
facial).  They  supply  the  skin  of  the  forehead,  of  the  eyelids,  the 
conjunctiva,  the  eyeball,  the  mucous  membrane  of  the  nostrils,  the 
integuments  of  the  face,  the  upper  lip,  the  nose,  the  beard  on  the 
upper  lip,  the  integument  of  the  ear,  the  temple,  and  the  whiskers; 
they  are  the  sensitive  nerves  to  these  regions.  The  inferior  maxil- 
lary has  two  distinct  sets  of  branches — the  one  by  which  the  muscles 
of  mastication  are  supplied ;  the  other,  which  go  to  the  integuments 
of  the  lower  lip  and  chin,  and  the  beard,  and  the  mucous  membrane 
of  the  mouth  and  tongue.  This  nerve  is,  therefore,  the  nerve  of  mas- 
tication, and  of  sensation  to  the  surfaces  above  named. 

"  Repeated  experiments  in  the  hands  of  various  physiologists, 
none  of  which,  however,  were  more  conclusive  than  those  of  Mayo, 
indicate  the  same  views  of  function.     Division  of  the  ophthalmic  or 


*  See  Todd  and  Bowman. 


THE  FIFTH  PAIR    OF  NERVES.  91 

of  the  superior  maxillary  induced  loss  of  sensibility  without  muscu- 
lar paralysis,  leaving  only  such  an  impairment  of  the  motor  power 
as  destruction  of  the  sensitive  nerves  invariably  produces,  by  im- 
pairing the  power  of  exact  adjustment,  for  which  a  high  degree  of 
sensibility  is  necessary.  But  when  the  inferior  maxillary  nerve  was 
cut,  then  both  the  power  of  mastication  was  destroyed  on  the  same 
side,  and  the  sensibility  of  the  lower  part  of  the  face  and  tongue  was 
lost.  If  the  nerve  were  divided  in  the  cranium,  the  whole  side  of 
the  face  and  forehead,  with  the  eyeball  and  nose,  became  insensible, 
and  the  muscles  of  mastication  were  paralyzed.  Irritants  might 
then  be  applied  to  the  eyeball,  without  exciting  winking,  or  causing 
pain,  and  strong  stimulants  might  be  introduced  into  the  nostrils 
without  creating  the  least  irritation.  When  the  trunk  of  the  nerve 
within  the  cranium  of  an  ass  was  irritated,  the  jaws  closed  with  a 
snap  from  the  excitation  of  the  motor  fibres,  which  are  distributed  to 
the  muscles  of  mastication. 

"  The  conclusions  which  we  draw  from  anatomy  and  from  experi- 
ment are  confirmed  by  the  histories  of  cases  in  which  the  fifth  nerve 
had  been  diseased.  In  such  instances  we  may  observe  the  most 
marked  separation  of  the  motor  and  sensitive  power,  when  the 
larger  portion  only  or  the  two  superior  divisions  of  the  nerve  are 
affected,  and  we  find  both  motion  and  sensation  destroyed  when  the 
whole  trunk  of  the  nerve  is  involved  in  the  disease.  It  is  not 
uncommon  in  such  cases  to  find  the  eyeball  totally  insensible  to 
every  kind  of  stimulus,  the  nose  quite  unexcitable  by  the  fumes  of 
ammonia  or  the  most  pungent  vapors,  and  the  mucous  membrane  of 
the  mouth  so  insensible  to  the  contact  of  foreign  matters  that  a  mor- 
sel of  food  will  sometimes  remain  between  the  gum  and  the  cheek 
until  it  has  become  decomposed.  The  insensibility  of  the  eyeball 
exposes  it  to  the  permanent  contact  of  irritating  particles  of  dust, 
etc.,  which  excite  destructive  inflammation  of  its  textures.  The 
whiskers  may  be  pulled  forcibly  without  sensation.  The  muscles 
of  mastication  become  wasted  and  inert,  as  shown  by  the  distinct 
depression  in  the  regions  of  the  masseter  and  temporal  muscles,  but 
the  superficial  muscles,  on  which  the  play  of  the  features  depends, 
preserve  their  natural  condition. 

"  The  fifth  nerve  may,  therefore,  be  regarded  as  the  motor  nerve 
in  mastication,  and  the  sensitive  nerve  to  that  great  surface,  both 
internal  and  external,  which  belongs  to  the  face  and  anterior  part  of 
the  cranium.  From  its  great  size,  and  the  large  portion  of  the  me- 
dulla oblongata  with  which  it  is  connected,  it   may  excite   other 


92  ORAL  DISEASES  AND  SURGERY. 

nerves  which  are  implanted  in  that  centre  near  to  it.  Thus  it  may 
be  an  excitor  to  the  portio  dura,  as  in  winking;  or  to  the  respiratory 
nerves,  as  in  dashing  cold  water  in  the  face,  or  in  sneezing.  Its  lin- 
gual portion  distributed  to  the  mucous  membrane  of  the  tongue  is 
at  once  a  nerve  of  taste,  touch,  and  common  sensibility,  and  its  con- 
nection with  the  papillary  structure  of  the  red  parts  of  the  lips  con- 
stitutes it  a  pre-eminently  sensitive  nerve  of  touch  in  those  regions. 
"  The  study  of  the  pathological  conditions  of  this  nerve  illustrates 
its  ph\^siology  in  a  highly  interesting  manner.  In  the  dentition  of 
children,  whether  primary  or  secondary,  it  is  always  affected,  more 
or  less  :  and  in  excitable  states  of  the  nervous  centres,  the  irritation 
of  it  consequent  upon  the  pressure  of  the  teeth  often  gives  rise  to 
convulsions,  the  brain  and  spinal  cord  being  irritated  ;  and  we  can 
often  trace  to  such  irritation,  whether  in  infancy  or  in  childhood,  the 
foundation  of  epileptic  seizures  in  subsequent  years.  Painful  affec- 
tions of  the  face  (^neuralgia)  have  their  seat  in  this  nerve ;  lie  dou- 
loureux, for  example.  Many  of  the  instances  of  painful  affection  of 
this  nerve  or  of  branches  of  it,  which  come  under  our  observation, 
are  well-marked  examples  of  reflected  sensation,  the  primary  irrita- 
tion being  conveyed  to  the  centre  Ijy  the  vagus  or  the  sympathetic 
from  the  stomach  or  intestinal  canal.  No  one  of  these  is  so  common 
as  the  pain  over  the  brow,  which  so  often  follows  derangement  of 
stomach  digestion ;  and  which  may  frequently  be  instantaneously  re- 
moved by  taking  away  the  source  of  irritation,  as  by  neutralizing  free 
acid  in  the  stomach.  Frequently  also  the  branches  of  this  nerve,  in 
greater  or  less  number,  on  one  or  both  sides,  may,  according  to  the 
humoral  view,  form  a  focus  of  attraction  for  a  morbific  matter  gen- 
erated in  the  blood,  in  persons  exposed  to  the  paludal  poison,  or  in 
persons  of  rheumatic  or  gouty  constitution  ;  in  these  cases,  as  in 
most  others  of  similar  pathology,  the  neuralgia  occurs  in  parox- 
ysms of  greater  or  less  severity,  each  paroxysm  being  followed  by  a 
period  of  convalescence,  which  lasts,  it  may  be  supposed,  until  tiie 
morbid  matter  has  been  again  accumulated  in  quantity  sufficient  to 
induce  a  high  degree  of  irritation  of  the  nerves." 


CHAPTER    IV 


DENTITION. 


The  direct  and  associative  lesions  of  the  teeth  being  so  common 
and  so  many,  the  study  of  the  diseases  of  the  mouth  will  naturally 
commence  with  these  organs. 

The  teeth  of  the  human  race  are  found  to  (;onsist  of  two  distinct 
sets.    The  first,  small  and  delicate,  pertain  to  infancy.     The  second, 

Fig.  37. — Dkciduous  Teeth  of  the  Left  Side — (After  T.  Bell.) 


Deciduous  teeth  of  the  left  side  of  the  jaws.  1  and  2,  incisors  ;  3,  cuspidati ;  4  ami  5, 

molars. 

when   normal,  are  in    like   manner   proportioned    to  the    strength, 
stature,  and  requirements  of  the  individual. 

The  first  set,  termed  milk,  deciduous,  or  temporary,  consist  of 
twenty  teeth — ten  in  either  jaw :  four  central  incisors,  four  lateral 
incisors,  four  cuspidati,  and  eight  molars.  The  second  or  permanent 
set  are  thirty-two  in  number — sixteen  in  either  jaw  :  four  central 
incisors,  four  lateral  incisors,  four  cuspidati,  eight  bicuspidati,  eight 
molars,  and  four  dentes  sapientise.  The  derivations  of  these  terms 
are  as  follows :  incisores,  from  the  Latin  verb  iricido,  to  cut ;  cuspidati, 
from  cusjns,  a  point;  bicuspidati,  from  bi,  two,  and  cu!<pit>,  point,  hav- 

(93) 


94 


ORAL  DISEASES  AND   SURGERY. 


ing  two  points ;  molares,  from  mola,  a  mill ;  denies  sapientiae,  teeth  of 
wisdom, — so  called  from  being  developed  in  mature  life. 

Fig.  3S. 


reriiiaiK-iit  tcetli  iil   Miperior  jaw. 

Nos.  1  and  2  of  Fig.  38  represent  the  incisor  teeth  of  the  upper 
jaw,  and  Nos.  1  and  2  of  Fig.  39,  the  incisor  teeth  of  the  lower  jaw. 
These  teeth  may  be  described  as  possessed  of  chisel-shaped  bodies  rest- 
ing upon  conoidal  roots ;  or  viewed  from  the  surgical  aspect,  they  are  to 
be  considered  as  two  cones,  the  bases  of  which  abut  just  beneath  the 
free  margin  of  the  gum.    In  number,  the  incisor  teeth  are  eight — four 


I'lMiiiiiiu-iit  tcftli  ut   interioi-  jaw. 

above  and  four  below  ;  these  are  classified  as  central  and  lateral.  The 
central  incisors  of  the  upper  maxilla  are  fully  one-third  greater  in 
breadth,  and,  indeed,  in  general  bulk,  than  the  lateral ;  a  condition 
found  reversed  in  the  inferior  jaw,  where  the  laterals  are  larger 
than  the  central,  although  not  to  the  same  extent  of  difference  as 
above.  In  length,  the  superior  central  teeth  are,  on  the  average, 
one  inch;  the  laterals  of  the  same  jaw,  from  one-third  to  a  fourth 
less.  Below,  while  the  depths  of  the  crowns  are  found  to  cor- 
respond, the  root  of  the  lateral  is  a  trifle  longer.  The  crowns  of 
the  superior  incisors  are  slightly  convex  in  front,  markedl}^  con- 
cave behind,  often,  indeed,  having  on  this  face  a  central  depression, 


DENTITIOy. 


95 


which,  from  imperfection  in  the  enamel  covering,  frequentl\^  becomes 
the  seat  of  caries.  The  inferior  incisors,  both  central  and  lateral, 
partake  more  of  the  wedge  shape.  The  enamel  of  the  incisors, 
being  most  markedly  exhibited  in  the  superior  centrals,  is  thickest 
at  the  cutting  face,  and  gradually  declines  toward  the  neck,  where  it 
terminates  in  an  abrupt  line  of  convex  aspect  in  front  and  behind,  the 
convexity  looking  toward  the  root.     At  the  sides,  the  enamel  forms 


Lateral  view  of  the  upper  and  lower  permanent  teeth.  1,  first  incisors;  2,  canines  ; 
3,  first  premolars  ;  4,  middle  molars. 

a  concave  line,  the  concavity  looking  toward  the  free  edge.  The 
line  of  the  enamel  corresponds  with  the  periosteal  relation,  and  in 
the  firmness  of  the  ring-like  fibres  of  this  tissue  exhibits  the  con- 
centration of  the  sac,  which,  before  the  eruption  of  the  teeth,  en- 
velops the  whole  crown,  only  a  portion  of  which  has  been  absorbed 
in  the  eruptive  act. 

The  Cusjndati — canines,  eye,  stomach  (3)  teeth — represent  the 
carnivorous  expression  in  our  species.  These  bodies,  spear-shaped  in 
general  form,  terminating  in  an.  obtuse  point,  are  convex  in  front, 
and  are  apt  to  vary  in  shape  behind.  Very  strong  and  fixed,  they 
serve  the  lower  animals  in  seizing  and  tearing  their  prey.  The 
roots  are  the  longest  of  all  the  teeth,  and  are  very  slightly  flattened 
cones.  The  superior  of  these  teeth  are  called  eye  teeth;  the  infe- 
rior, stomach  teeth. 


96 


ORAL  DISEASES  AND   SURGERY. 


Fio.  41. 


The  Bicuspidati — premolars — (4  and  5)  have  rounded  crowns, 
with  a  double-cusped  grinding  surface  and  intervening  sulcus.  The 
roots  of  these  teeth  are  decidedly  flattened,  and  iu  the  anterior  are 

apt  to  have  a  longitudinal  division  which 
frequently  separates  the  single  fang  into 
two  parts.  Occasionally,  though  ver}" 
rarely,  these  teeth  will  be  found  to  have 
three  distinct  roots. 

The  Molars  (6  and  7)  have  crowns 
of  cuboid  shape,  are  four-cusped,  and 
roughened,  for  purposes  of  trituration. 
The  superior  have  each  three  conoidal 
roots;  two  of  these  are  situated  antero- 
posteriorly ;  the  third,  somewhat  flat- 
tened, looks  toward  the  palatine  aspect. 
The  inferior  have  two  roots,  the  inter- 
space being  buccal  and  lingual. 

The  Denies  Sapienliee  (8)  are  in  re- 
alit}^  the  third  molars;  they  dilfor,  how- 
ever, in  being  somewhat  smaller,  and  in 
having  commortly  but  a  single  root,  al- 
thougli  this  root  may  be  recognized  as  a 
blending  of  the  roots  distinguishing  the 
other  molars.  It  commonly  curves  back- 
ward. 

The  names  of  the  teeth,  expressed  in 
the  singular  number,  are,  incisor,  cuspi- 
datus,  bicuspidatus,  molar,  dens  sa- 
pientiae. 

Figs.  41  and  42  show  teeth  in  sec- 
tion. In  the  centre  is  a  cavity,  occu- 
pied by  a  pulp,  the  tooth-pulp :  that 
which  is  its  analogue,  a  periodonteum, 
envelops  the  roots.  These  membranes 
are  the  nutrient  vehicles  of  the  organ,  holding  and  conveying  the 
blood-vessels  and  nerves.  Yariations  in  the  shape  and  relationship 
of  the  pulp  cavity  are  matters  of  surgical  interest,  as  not  unfre- 
quently  a  near  approach  to  the  neighborhood  of  the  surface  allows 
its  exposure  by  a  very  limited  caries. 

A  tooth  is  divided  into  three  pai'ts:  a  crown,  root  or  fang,  and 
neck.     The  crown  of  a  tooth  is  the  exposed  part ;  the  fang,  the  part 


A'Er.TlL'AL  M.lTI'.iV  111-  A  .M"LaU  TO'JTII, 

indderatc'ly  niagiiifii'd.  1,  enaiiiel, 
the  lines  of  which  indicate  the  ar- 
rangement of  its  columns;  2,  den- 
tine, the  lines  indicating  the  course 
of  its  tubules ;  3,  thin  lamina  of  the 
dentine  forming  the  wall  of  the  pulp 
cavity,  the  dots  indicating  the  ori- 
fices of  the  dentinal  tubules;  4, 
cement. 


TuANSVKnst;  skition   uf  a   mdlar 

TOOTn  OF  TUE  NATURAL  SIZE.    (^Tlie  CUt 

is  made  through  the  body  of  the 
tooth.)  1,  dentine;  2,  enamel;  3, 
cavity. 


DENTITION. 


97 


Fig.  43. 


which  associates  it  with  the  jaw  ;  the  neck,  the  intermediate  part. 
A  tooth  is  composed  of  five  structures  :  1,  pulp ;  2,  dentine  ;  3> 
enamel ;  4,  crusta  petrosa,  or  cementum  ;  5,  periodonteum. 

In  the  centre  of  the  section  (Fig.  43)  is  exhib- 
ited the  pulp  enlarged  by  the  microscope  :  this 
body  is  shown  to  be  a  mass  of  delicate  con- 
nective tissue,  in  which  ramify  blood-vessels 
and  nerve-filaments.  See  Figs.  44,  45.  It 
has  no  enveloping  membrane  proper,  as  will 
be  understood  in  the  study  of  odontogeny; 
it  is  the  original  papilla,  or  tooth  germ. 
Through  the  vessels  of  this  body,  the  inter- 
nal structure  of  the  tooth  is  nourished ;  in 
its  death  the  tooth  loses  its  translucency, 
becoming  discolored  and  opaque,  —  being, 
indeed,  devitalized,  except  as  nourishment  is 
received  from  the  periodonteum.  The  pulp 
of  a  tooth  is  so  highly  endowed  with  nerve- 
matter  that  the  slightest  touch  suffices  to  pro- 
voke the  most  exquisite  pain. 

Dentine. — The  dentine,  or  dentinal  portion 
of  the  tooth,  is  marked  2  in  the  diagram 
(Fig.  43).  This  substance  is  called,  also,  the 
ivory.  While  histological  dispute  exists  as 
to  the  real  constitution  of  this  structure,  a 
full  surgical  signification  is  found  in  accepting 
it  as  a  fibro-calcareous  stroma,  tubular  in 
character.     These  tubuli,  commencing  at  the 

enamel  membrane,  the  original  tunica  propria  (see  Dentition),  ap- 
proach the  pulp,  opening  into  the  cavity  by  capillary  mouths,  and 
thus  receive  the  halitus  which  is  their  nutrition.  The  tubuli  of 
dentine  are  in  some  instances  almost  straight,  at  other  times  curvi- 
linear. In  the  neighborhood  of  the  enamel  they  are  dichotomous 
and  trichotomous.  Figs.  46  and  47  show  these  varieties  of  tubes. 
Fig.  49  shows  the  tubes  in  transverse  section.  (For  mode  of  forma- 
tion of  dentine,  see  author's  views  on  Dentition.) 

Enamel. — No.  3,  Fig.  43,  exhibits  the  position  and  relation 
of  the  enamel  as  a  cap  to  the  crown  portion  of  the  tooth.  This 
structure  is  almost  entirely  inorganic  in  its  composition,  containing 
but  about  two  per  cent,  of  animal  or  living  matter  ;  it  is  hard,  flinty, 
brittle,  and  decreases  in  thickness   as  it  passes   from  the   cutting 

T 


Vertical  section  of  a  cuspid 
tooth. 


98 


ORAL   DISEASES  AND  SURGERY. 


face  to  the  neck  of  the  tooth.     Id  composition,  enamel  is  made  up 
of  a  series  of  hexagonal  fibres,  having  a  double  direction,  by  which 


Fig.  44. 


Dental  pulp,  maguified. 


Fig.  45. 


Nerves  of  deutal  pulp. 


each  becomes  strengthened  bv  its  fellow  as  it  is  crossed  and  recrossed, 
one  set  undulating  outward,  another  crosswise.     The  nutrition  of 

Fig.  46. 


1,  tubuli  of  dentine;  2,  enamel. 


the  enamel  is  received  through  the  tunica  propria.    (See  Dentition.) 
Cementum,  or   Crusta  Petroaa. — Fig.  43   (1)  exhibits   the  rela- 


Fig.  47. 


Vertical  section  of  thf  fang  of  a  canine  tooth,  exhibiting  the  structure  of  the  den- 
tine and  cement.  1,  inner  extremities  of  the  dentinal  tubules ;  2,  outer  extremities  of 
the  tubules,  terminating  in  interspaces  at  the  boundary  of  the  dentine;  3,  cement;  4, 
lacunae  like  those  of  bone.    Highly  magnified. 


/ 


DENTITION. 


99 


tion  of  the  cement  as  a  sheathing  to  the  fang.     This  structure  so 
closely  resembles  bone  proper  as  to  be  liable  to  the  diseases  of  that 


Fig.  48. 


%r 


FiG>  49. 


Three  ejiamel  columns,  highly  magnified; 
exhibiting  the  six-sided  prismatic  and  waving 
character. 


Section  of  ewmel,  highlj'  magnified,  at  right 
angles  to  the  course  of  its  columns ;  exhibit- 
ing the  six-sided  character  of  the  latter. 


Fm.  50. 


structure,  and  possesses  all  its  chemical  elements.  A  thick  cemen- 
tum  contains  well-marked  Haversian  canals  and  Purkinjean  corpus- 
cles or  lakelets.  (See  manner  of  its  formation  in  Dentition.) 

Periodonteum. — This  is  the  analogue  of  the  periostea  of  the  com- 
mon osseous  structures.    It  is  a  composition  of  fibrous  tissue,  serving 
the  double  purpose  of  attaching  the  teeth  to  their  alveoli  and  support- 
ing the  external  vessels  of  nu- 
trition.   At  the  neck  of  a  tooth 
it  is  found  dense  and  resist- 
ing ;  toward  the  apex  it  atten- 
uates to  softness  and  delicacy. 

Interglobular  spaces. — Fig. 
50  exhibits  what  are  termed 
interglobular  spaces,  as  seen 
in  the  dentine  of  certain  teeth  : 
these  spaces  possess  much  sur- 
gical interest,  as  it  is  to  be 
presumed  they  represent  an 
imperfect  development,  and 
thus  explain  the  rapid  break- 
ing down  of  many  teeth.  In 
an  exhaustive  paper  on  this 
subject,  b}^  Dr.  J.  H.  McQuil- 
l^ijf  (see  Dental  Cosmos,  vol. 
vi/i.  p.  113),  that  gentleman 
remarks,  **  As  evidence  of  the 

[practical  bearings  of  these  investigations,  it  may  be  well  to  direct 
attention  to  the  fact  that  the  existence  of  the  spaces  in  teeth  which 
'nave  completed  their  growth  must  be  regarded  as  an  abnormal  condi- 


Interglobular  spaces. 


100  ORAL   DISEASES  AND   SURGERY. 

Hon,  predisposing  such  teeth  to  decay,  and  that  when,  either  by 
mechanical  action,  as  by  a  fall  or  blow,  or  by  the  penetration  of 
external  caries,  such  spaces  are  reached,  the  disease  here  would  run 
riot ;  hence  the  importance  of  care  on  the  part  of  patients  and  oper- 
ators to  have  the  most  minute  cavities  filled  ;  for  though  reached  only 
through  a  microscopical  opening,  the  result  would  be  the  same, 
while,  if  protected  from  the  action  of  external  influences  or  the  ex- 
citing causes  of  decay,  this  predisposition  might  remain  dormant 
for  a  lifetime,  as  is  sometimes  the  case  with  other  diseases." 

Relation  of  the  Teeth  ivith  the  Jaw. — The  teeth  associate  with 
the  jaw  through  the  intervention  of  a  peculiar  cellular  bone  described 
as  the  alveolar  processes.  This  structure,  as  has  been  seen,  is  hol- 
lowed into  pits  corresponding  with  the  shape  of  the  roots  accom- 
modated by  them.  In  some  persons  this  process  is  very  spongy, 
in  others  it  almost  resembles  in  density  the  cortical  portion  of  the 
bone ;  in  proportion  to  this  density  are  teeth  found  loosely  or  firmly 
fixed,  and  it  is  also  a  matter  of  experience  that  in  proportion  as  this 
process  is  solid  are  the  teeth  resistive  of  disease.  This  arises,  of 
course,  from  these  organs  corresponding  with  the  nature  of  the 
bone,  and  being  to  such  extent  isolated  from  systemic  impressions. 
No  stronger  proof  could  be  afforded  of  the  constitutional  or  vital 
relationship  of  caries. 

We  may  from  such  general  consideration  pass  to  an  examination 
of  the  subject  of  the  process  of  the  development  and  growth  of  the 
teeth. 


CHAPTER  T. 

DENTITION — CONTINUED. 

In  the  foetus  of  six  weeks  is  to  be  observed,  at  the  border  of  the 
palate,  a  groove  occupying  the  position  of  the  future  teeth.  This 
groove  is  called  the  primitive  dental ;  scattered  along  the  bottom  of 
it  are  certain  fine  papillae,  which,  in  their  development,  are  found 
gradually  to  assume  the  shape  of  the  crowns  of  teeth.  As  these 
papillae  grow,  the  groove  is  converted  into  a  series  of  distinct  folli- 
cles for  their  accommodation  by  the  growth  of  septi  between  the 
papilla,  which  septi  soon  begin  to  ossify,  to  assist  in  forming  the 
bony  sac  or  alveolus  common  to  the  perfected  teeth.  It  is  seen, 
however,  that  the  septi  complete  only  a  circumferential  boundary, 
the  summit  of  the  papilla  being  exposed.  Before,  however,  the 
papilla  has  assumed  the  form  of  the  tooth,  the  upper  soft  margin  of 
the  pit  enlarges  and  falls  over,  forming  an  operculum  or  lid. 

The   tooth  thus  forming  is   generally  regarded  as  a  cutaneous 
production,  and  would  seem  to  be  a  modification  of  the  hair   or 
nail.     If  such  inference  is  an  error,  and  this  body  is  not  such  a 
production,  it  is  plainly  enough   seen  that  the  papilla,  being  sab- 
mucous,  enveloped  or  overlaid   by  the  mucous   membrane  lining 
the  primitive  groove,  must,  in  its  development,  either  rupture  this 
envelope,  or  assume  and  modify  it.     Now,  what  is  the  state  of  the 
case  ?     According  to  the  observations  of  Goodsir,  and  the  opinion 
of  Todd  and  Bowman,  "the  tooth  papilla   must   be  regarded  as 
homologous  with,  or  answering  to,  the  tactile  and  hair  papilla  of  the 
skin,  and  it  would  therefore  be  expected  that  its  main  part  would 
consist  of  a  peculiar  submucous  tissue,  covered  by  a  homogeneous 
basement  membrane,  and  surmounted  by  a  tissue  answering  to  the 
epithelium.     The  substance  of  the  papilla  is,  at  first,  a  congeries  of 
granular  nuclei,  dispersed  irregularly  through  a  firm,  homogeneous, 
subgranular  matrix  or  blastema,  in  which  vessels  and  nerves  are 
by  degrees  developed      This  is  bounded  by  a  definite  transparent 
membrane,  on  which  rests  a  reflection  of  the  epithelium  lining  the 
sac,  modified  in  structure  so  as  to  present  a  series  of  columnar, 

(101) 


102  ORAL  DISEASES  AND  SUBGERY. 

nucleated  particles,  the  matrix  of  the  future  enamel."  It  would 
appear,  according  to  these  observers,  that  the  lining  and  reflected 
layers  of  the  epithelium  become  blended  together,  and  constitute  but 
one,  which  is  more  adherent  to  the  sac  than  to  the  papilla;  so  that 
on  opening  the  sac  its  walls  generally  seem  unattached  to  the  surface 
of  the  papilla,  and  the  latter  to  be  limited  to  what  has  been  regarded 
as  the  basement  membrane. 

The  growth  of  the  papilla,  thus  circumstanced,  is  considered  by 
these  authors  as  follows :  "  Between  the  columnar  epithelium  lining 
the  sac  and  the  surface  of  the  alveolar  cavity,  that  is,  apparently  in 
the  wall  of  the  sac  itself,  is  found  a  thick,  semi-transparent,  pulpy 
tissue,  which  has  been  termed  the  enamel  pulp.  It  presents  toward 
the  pulp  of  the  tooth — that  is,  toward  the  original  papilla — a  series 
of  elevations  and  depressions  precisely  the  reverse  of  those  of  the 
dentinal  pulp  on  which  they  rest,  and  answering  mutually  to  these, 
with  only  the  columnar  epithelium  intervening.  The  structure  of 
this  pulpy  tissue  is  elastic,  spongy,  loaded  with  fluid  albumen,  but 
destitute  of  vessels. 

"  In  a  vertical  section  of  these  parts,  the  enamel  pulp  is  seen 
covered  with  columnar  epithelium,  the  enamel  matrix  on  the  surface 
toward  the  dentinal  or  tooth  pulp;  while  on  the  opposite  surface 
the  blood-vessels  of  the  membrane  lining  the  alveolus  are  seen 
coming  up  to  and  forming  loops  immediately  under  the  enamel 
pulp,  without  penetrating  it.  It  is  further  remarkable  that  short 
tubes,  filled  with  glandular  epithelium,  descend  among  these  vessels 
from  the  enamel  pulp,  and  end  by  blind  extremities,  *  How  these 
tubes,  which  are  evidently  glandulai',  can  discharge  their  contents, 
it  is  diificult  to  understand,  seeing  they  appear  to  open  into  the  sub- 
stance of  the  enamel  pulp. 

"  The  next  stage*  is  that  of  ossification ;  and  the  earthy  matter  is 
first  deposited  in  the  homogeneous  membrane  forming  the  dentinal 
pulp.  The  most  prominent  portions  of  the  crown  are  the  first  to 
harden;  and  the  ossification  proceeds  inward  by  the  gradual  conver- 
sion of  the  pulp  into  the  dentine  or  ivory.  The  nucleated  particles  of 
the  pulp  nearest  the  ossifying  surface  are  found  arranging  themselves 
in  series  vertical  to  that  surface;  and  it  appears  that,  in  order  to 
form  these  vertical  series,  they  multiply  by  transverse  division, 
much  as  those  of  bone  cartilage  are  found  to  do.  The  earthy  matters 
are  then  deposited  in  the  indistinct  cells  surrounding  the  nuclei,  so 

*  Observations  of  Goodsir,  Todd  and  Bowman,  continued. 


I 


DENTITION.  103 

as  to  form  the  hard  and  dense  walls  of  the  dentinal  tubes,  as  well 
as  the  intercellular  substance,  so  as  to  form  the  intertubular  tissue  of 
the  perfect  tooth.  The  cells  unite  endwise,  and  their  nuclei  elongate 
and  coalesce  in  a  manner  to  constitute  the  cavities  of  the  tubes,  and 
so  as  often  to  retain  this  mode  of  origin  in  their  permanent  form. 

"  The  calcification  of  the  enamel  commences  on  the  surface  of  the 
dentine  in  contact  with  that  primary  osseous  sheet  formed  from  the 
basement  membrane  of  the  dentinal  pulp.  On  this  primary  layer 
are  minute  shallow  cups,  closely  aggregated,  answering  to  the  ends 
of  the  enamel  columns  and  receiving  them  in  a  firmly  cemented 
union,  as  the  consolidation  of  the  elementary  cells  proceeds.  The 
enamel  columns  at  a  very  early  stage  seem  to  consist  only  of  a 
single  series  of  nucleated  particles,  intervening  between  the  dentine 
and  enamel  pulp.  Those  of  the  new  row  arrange  themselves  end- 
wise on  the  others,  which  they  resemble  in  all  respects,  so  that  the 
enamel  attains  its  proper  thickness  rather  by  the  superposition  of 
particle  or  particles  successively  deposited,  and  by  the  subsequent 
calcification  of  each  in  its  turn,  than  by  the  development  of  its  parts 
by  an  interstitial  increase  ;  and  thus  it  appears  to  differ  from  the 
dentinal  pulp  and  to  resemble  the  epithelium,  to  which  it  is  allied. 

"  It  is  from  that  surface  of  the  enamel  pulp  which  looks  toward 
the  tooth  that  this  successive  development  of  new  enamel  columns 
proceeds ;  as  they  form,  this  tissue  wastes ;  but  it  is  not  probable 
that  the  pulp  is  converted  into  the  columns,  as  the  dentinal  pulp  is 
converted  into  dentine,  because  the  anatomical  characters  of  the 
pulp  are  so  dissimilar  from  those  of  the  columns.  When  first  calci- 
fied, the  enamel  rods  are  loosely  aggregated,  and  easily  separate 
from  one  another  under  pressure ;  but  they  gradually  become  so 
consolidated  by  the  advance  of  the  calcifying  process  in  their  inter- 
stices, as  to  make  the  finished  enamel  the  most  hard  and  indestruc- 
tible of  all  the  products  of  organization. 

"  The  development  of  the  layer  containing  the  ordinary  lacunae 
of  bone,  and  which  in  the  human  teeth  covers  the  fang,  and  is  con- 
tinued a  little  way  within  the  cavity  of  the  root,  does  not  seem  to 
have  been  as  accurately  studied  as  that  of  the  dentine  and  enamel. 
There  can  be  little  doubt  that  a  membranous  matrix,  probably  like 
that  of  the  cranial  bones,  is  laid  down  as  the  fang  is  developed,  in 
which  the  usual  steps  of  ossification  precede  the  lacunae  and  their 
canaliculi,  being  formed  from  the  corpuscles  of  the  temporary  matrix. 

"When  the  ossification  of  the  dentine  is  so  far  advanced  that  the 
tooth  can  sustain  with  impunity  the  pressure  to  which  it  is  destined, 


/ 


104  ORAL  DISEASES   AND   SURGERY. 

and  when  the  enamel  is  densely  calcified,  the  eruptive  stage  occurs, 
in  which  the  tooth  makes  its  way  through  the  gum.  This  is  due 
to  the  same  law  of  development  which  governs  the  form  and  position 
of  other  organs.  The  gum  over  the  sac  is  absorbed,  and  the  crown 
of  the  tooth  is  forced  upward  against  it,  chiefly  by  the  increasing 
size  of  the  fang  below. 

*'  As  the  development  of  the  teeth  proceeds,  does  that  also  of  the 
alveoli:  so  that  by  the  time  the  teeth  emerge  through  the  gums, 
their  walls  are  sufficiently  strong  and  embrace  the  necks  with  firm- 
ness enough  to  furnish  a  solid  basis  of  support.  Their  vascular 
canals  are  developed,  and  especially  those  which  convey  to  each 
tooth  its  interior  supply  of  vessels  and  nerves.  The  gums  and  alveoli 
are  likewise  provided  with  vessels  which  play  their  part  in  the  devel- 
opment and  subsequent  nutrition  of  the  organs." 

These  are  the  views  of  development  entertained  by  the  authors 
above  mentioned.  The  later  writers — Beale,  Huxley,  Tomes,  etc. 
— I  have  not  quoted,  because  a  review  renders  it  sufficiently  evi- 
dent that  no  one  of  them  is  fixed  in  his  deductions  or  conclusions. 
Investigations  made  by  myself  in  the  direction  have  seemed  to  me' 
to  simplify  the  matter  very  much,  and,  indeed,  to  deprive  it  of  a 
very  great  share  of  its  obscurity.  Whether  these  views  may  be 
nearer  right  than  the  various  others  held,  the  physiologist  may  for 
himself  determine.  I  must  be  allowed  to  admit  that  I  deem  them 
irrefutable. 

At  a  certain  period  of  foetal  life,  as  has  been  remarked,  a  groove  is 
observed,  the  progressive  development  of  which  proves  it  to  be  the 
primitive  dental  groove.  This  groove  is  lined  by  a  delicate  mem- 
brane continuous  with  the  mucous  membrane,  indeed  a  part  of  it, — 
modified,  but  still  of  it,  just  as  the  conjunctival  cells  which  pass  over 
the  cornea  are  really  part  and  parcel  of  the  common  ocular  conjunc- 
tiva. This  membrane,  at  points  corresponding  with  the  position  of 
future  teeth,  is  seen  to  be  elevated  into  little  hills.  A  section  through 
the  membrane,  over  any  of  these  hills,  exposes  a  papilla.  This  papilla 
or  body,  closely  examined,  is  found  to  be  made  up  of  a  congeries 
of  granular  nuclei,  dispersed  irregularly  through  a  firm  homoge- 
neous blastema.  This  papilla  is  the  rudiment  of  a  future  tooth,  as 
observation  of  its  development  proves.  It  is  not  inclosed  in  a 
cell-wall  or  membrane  of  its  own,  but  is  a  hyaloid  structure  or 
substance.     The  body,  thus  understood,  is  seen  to  lie  beneath  the 


DENTITION.  '  105 

mucous  membrane  ;  and  in  this  membrane  resides  a  certain  amount 
of  elasticity.  As  the  papilla  enlarges  and  projects  itself,  it  becomes 
inclosed  to  all  the  extent  possible  with  this  mucous  membrane  con- 
tracted about  the  body  so  as  to  constitute  a  sac  or  cell  wall,  pre- 
cisely as  the  parietal  peritoneum  contracts  about  and  makes  a  sac 
to  the  projected  intestine  in  hernia.  This  sac  enveloping  the  papilla 
has  its  continuation,  as  is  seen,  necessarily  over  the  sides  of  the 
groove ;  as,  then,  this  groove  enlarges  and  deepens,  and  finally  en- 
velops the  papilla,  it  is  seen  that  the  body  or  tooth  germ  gets  a 
second  sac.  It  is  as  though  one  should  envelop  his  head  in  a  double 
night-cap,  and  then  bind  over  this  a  handkerchief, — the  submucous 
structure  of  the  lateral  walls  and  operculum  representing  the  hand- 
kerchief. 

At  this  period,  the  pulp,  or  original  papilla,  having  attained  the 
size  of  the  tooth  it  represents,  commences  the  process  of  the  forma- 
tion of  dentine.  Before  the  attainment  to  full  size  of  the  papilla, 
there  existed  between  it  and  its  sac  proper  a  halitus  or  fluid.  This 
halitus,  now  that  the  congeries  of  cytoblasts  or  nucleated  granules 
have  obtained  their  full  growth  and  secretive  power,  is  replaced  by 
a  more  highly  endowed  secretion,  the  work  of  these  matured  cells. 
This  secretion,  deposited  against  the  inner  sac,  or  between  it  and 
the  pulp,  contains  the  elements  of  the  dentinal  structure,  is,  indeed, 
the  dentine,  and  deposits  layer  after  layer,  supported  by  and  moulded 
into  form  by  the  sac.    Calcification  is  progressive  with  its  formation. 

As  this  deposit  intrudes  on  the  pulp,  so  this  body  contracts  within 
itself,  until,  finally,  by  some  law  of  nature,  it  stops  at  that  certain 
point  which  maintains  within  the  tooth  a  canal  or  cavity,  and  a  vas- 
cular and  nervous  pulp  to  occupy  it, — this  pulp  being  the  contracted 
original  papilla  ;  the  vessels  of  this  papilla  are  vessels  entirely  analo- 
gous to  any  one  of  the  ordinary  papillae  of  touch,  so  supplied  and  so 
maintained. 

Why  this  secretion,  in  its  organization,  should  assume  the  position 
of  the  elongated  tubular  cells  which  pertain  to  the  structure  of 
dentine,  I  have  of  course  no  idea,  and  it  is  quite  enough  for  our 
purpose  to  say  that  it  is  a  law  of  form  perhaps  not  to  be  compre- 
hended, and  the  discovery  of  which  would,  at  any  rate,  have  but 
little  practical  signification  to  us. 

The  formation  of  the  dentine  completed,  the  covering  of  it  with 
enamel  begins;  or  rather  this  deposit  is,  to  a  degree,  coincident  with 
the  dentinal  formation.  Secreted  by  the  same  pulp  which  formed 
the  dentine,  the  same  secretion,  some  portion  finds  its  way  into  and 


106  ■      ORAL  DISEASES  AND  SURGERY. 

through  the  primary  sac.  As  it  passes  through  this  sac  it  is  modi- 
fied, receives  new  elements,  perhaps,  which,  as  it  is  received  into  the 
second  space,  or  the  space  between  the  first  and  second  caps,  im- 
presses upon  it  the  arrangement  of  its  particles  after  the  hexagonal 
order  of  the  enamel.  Between  the  enamel,  thus  formed,  and  the 
dentine,  exists  the  primary  sac;  simply  the  originally  modified 
mucous  membrane,  which  we  first  saw  as  overlying  the  papilla.  This 
membrane  continues  its  existence  between  these  two  hard  bodies, 
and  receives  and  modifies,  for  the  support  of  the  enamel,  the  liquor 
sanguinis  exuded  from  the  dentinal  tubules  and  intertubular  struc- 
ture. It  may  be  called  the  enamel  membrane.  It  has,  of  course, 
been  much  modified;  it  is  from  it  that  we  receive  the  impressions 
of  pain  when  becoming  exposed  by  a  break  in  the  continuity  of 
enamel.  The  views  propounded  and  exhibited  by  Mr.  Tomes  of  the 
primary  calcification  of  a  membrane  covering  the  dental  pulp,  and 
which,  by  his  assertion,  forms  the  exterior  of  the  dentine,  can  only 
be  a  microscopical  fallacy.  A  membrane  does,  without  doubt,  exist, 
but  it  is  the  delicate  tunica  propria,  and  it  becomes  calcified  only 
pathologically,  and,  when  calcified,  the  enamel  becomes  brittle  and 
dead,  as  thus  its  nutrition  is  cut  off. 

The  growth  of  the  root  of  a  tooth,  as  its  dentine  is  concerned, 
has  precisely  the  history  of  the  body.  It  is  associated  with  the 
pyramidal  elongation  of  the  papilla  or  pulp,  which,  pushing  upward 
the  crown,  elongates  upon  itself  the  enamel  membrane.  This  elonga- 
tion, with  a  greater  vascularity  and  vitality  assumed  by  the  mem- 
brane as  it  approaches  the  basement  vessels,  modifies  again  the 
result  obtained  by  the  exudate  passing  through  it  from  the  dentinal 
pulp,  the  result  being  a  nearer  approach  to  true  bone  in  the  produc- 
tion of  cementum. 

The  Periodonteum  is  the  modified  external  sac,  lost,  of  course, 
above  the  neck,  as  the  tooth  has  emerged  through  it. 

This  is  a  very  simple  and  easily  understood  explanation  of  tooth 
growth.  The  observations  leading  to  the  conclusions  have  been 
somewhat  extensive,  and  the  phenomena  seem  certainly  indorsed  by 
general  physiological  analogy. 

We  pass  here  to  what  infinitely  more  concerns  us  as  practitioners, 
— namely,  the  relations  of  the  first  and  second  dentitions. 

Of  the  first  set,  the  papillae  of  the  anterior  molars  appear  first,  the 
canines  and  incisors  next,  and  the  posterior  molars  last.     About  the 


DENTITION. 


107 


fourth  month  these  papillae  are  all  in  their  saccular  envelopes,  and 
forming  behind  the  lids  of  the  sacs  are  little  crescentlc  depressions, 
called  cavities  of  reserve,  lined  with  mucous  membrane,  and  con- 
taining the  germs  of  the  papillae  of  the  second  set  of  teeth, — one 
to  each  deciduous  germ.  The  first  molar  of  the  permanent  set 
is  markedly  related  to  the  deciduous,  by  having  a  common  origin 
from  and  in  the  primitive  dental  groove ;  from  sacs,  secondary  to 
the  capsule  of  this  tooth,  spring  the  reserve  cavities  of  the  second 
and  third  molars  of  the  second  set. 


Fig.  51. 


y^C 

^  ^(g^^ 


Diagram  of  the  mode  op  development  op  the  teeth,  a,  section  across  the  dental 
groove ;  6,  papilla  developed  in  the  latter ;  c,  the  groove  deepened  and  processeg  forming 
which  ultimately  close  it ;  d,  the  groove  becoming  closed ;  e,  dental  sac  containing  a 
dental  pulp,  which  is  the  rudiment  of  the  crown  of  a  temporary  incisor ;  the  cavity  above 
is  reserved  for  a  permanent  incisor ;  /,  the  crown  of  the  temporary  incisor  fully  formed, 
and  the  reserved  cavity  for  the  permanent  tooth  moving  backward ;  g,  fang  of  the  tem- 
porary incisor  produced,  and  origin  of  the  dental  papilla  of  the  future  permanent  tooth; 
h,  eruption  of  the  temporary  incisor,  and  the  alveoli  produced  for  both  teeth  ;  i,  the  tem- 
porary incisor  occupying  its  functional  positioa,  and  the  crown  of  the  permanent  incisor 
developed. 

The  eruption  of  the  temporary  set,  although  more  or  less  irregular, 
ensues,  as  a  rule,  in  the  following  order  and  time, — the  lower  teeth 
erupting  first :  the  central  incisors  about  the  seventh  month,  the 
lateral  incisors  about  the  eighth  month,  the  anterior  molars  about 
the  thirteenth  month,  the  canines  about  the  sixteenth  month,  and 
the  posterior  molars  about  the  twenty-fourth  month.  The  age 
intervening  between  the  first  and  the  last  eruption  is  considered  the 
critical  period  in  infantile  existence-  (See  chapter  on  Associated 
Lesions  of  First  Dentition.) 


108  ORAL  DISEASES  AND   SURGERY. 

The  ossification  of  the  permanent  teeth  commences,  just  before 
birth,  with  the  anterior  molars,  proceeding  forward,  but  terminating 
with  the  premolars  at  about  the  third  year ;  this  description  does  not, 
however,  include  the  posterior  molars,  which  are  really  the  last  to 
ossify. 

The  position  of  the  permanent  papillae,  which  at  first  are  situated 
between  the  sacs  of  the  deciduous  and  the  gum,  gradually  recedes 
behind,  falling  deeper  and  deeper,  at  least  relatively  so,  as  the  milk 
set  elongates ;  until,  on  the  completion  of  growth  in  the  deciduous, 
the  germs  of  the  permanent  set  are  found  in  the  common  alveoli  at 
the  apices  of  these  cavities,  occupying,  indeed,  almost  the  position 
and  physiological  relations  of  the  original  papillae. 

At  this  period,  whenever  it  may  be,  and  it  varies  of  course  with 
different  individuals,  commences  a  process  of  antagonism :  it  is 
intended  that  the  new  shall  advance  and  increase,  that  the  old  shall 
decline  and  diminish.  The  relative  position  of  the  two  bodies  is  as 
follows :  extending  to  the  apices  of  the  alveoli,  and  receiving  at  these 
apices  the  principal  vessels  of  nutrition,  are  the  perfected  roots  of 
the  first  teeth.  Crowding  down  into  these  alveoli,  with  nutritious 
vessels  of  their  own,  possessed  with  the  high  vitality  of  growing 
bodies,  are  the  pulps  of  the  second  teeth.  As  these  pulps  enlarge, 
so  is  there  a  corresponding  enlargement  in  the  alveoli  containing 
them,  until,  finally,  through  such  process  of  absorption  they  have 
fallen  directly  beneath  the  roots  of  the  first  set.  Of  course  a  pressure 
has  been  equally  exerted  upon  these  roots,  and,  as  a  result,  the 
nutrient  vessels  passing  into  the  pulp  cavities,  through  the  fora- 
mina at  the  apices,  have  been  gradually  obliterated.  But  do  the 
pulps  of  the  milk  teeth  die  ?  Not  at  all ;  or  at  least  not  necessarily. 
The  neighboring  vascularity  is  very  great,  the  requirements  of  the 
organ  very  small ;  a  sufficient  supply  is  received  from  the  circulation 
in  the  dentine,  as  well  as  from  the  periodonteum,  which,  to  the  last, 
continues  to  close  in  the  enlarging  foramina.  But  this  does  occur: 
the  absorbent  or  destructive  system  has  been  given  the  mastery, 
and  little  by  little,  day  by  day,  and  month  by  month,  the  roots  of 
the  first  teeth  disappear,  while  the  crowns  of  the  second  advance, 
and  occupy  the  space  gained,  until  at  length,  as  is  witnessed  every 
day,  the  milk  tooth  drops  out  of  the  cavity,  minus  a  root,  while  the 
crown  of  the  permanent  is  seen  in  its  place. 

If  here  we  take  up  this  throwu-off  tooth,  we  shall  find  that  the 
pulp  chamber,  or  what  remains  of  it,  instead  of  having  an  almost 
complete  bony  envelope,  as  is  the  case  in  the  perfect  organ,  has 


DENTITION. 


109 


communicated  more  and  more  largely,  for  a  varying  period,  with 
the  soft  parts,  guarding  us,  in  such  knowledge,  against  a  treatment 
in  aching  milk  teeth,  at  certain  periods,  which  would  be  most  appli- 
cable at  others. 

To  judge  of  the  condition  of  the  foramina  of  the  first  teeth,  we 
compare  them  with  periods  of  eruption  of  the  second,  recognizing 
that  the  enlargement,  or  absorption,  corresponds  with  such  advance 
in  the  permanent. 

The  first  teeth  of  the  second  set  erupt  entirely  back  of  the  tem- 
porary, and  in  no  way  interfere  with  them.  These  are  the  anterior 
or  first  molars,  and  appear  commonly  at  about  the  sixth  year, 
seldom  earlier,  but  not  unfrequently  from  one  to  several  months 
later ;  the  sixth  year,  however,  is  the  rule.  The  second  teeth  to 
appear  are  the  central  incisors,  the  lower  a  little  in  advance  of 
the  upper — about  the  seventh  year  ;  the  third,  the  lateral  incisors, 
at  the  eighth  year;  the  fourth,  the  anterior  premolars,  at  the  ninth 
3'ear ;  the  fifth,  the  posterior  premolars,  at  tha  tenth  year ;  the  sixth, 
the  canines  or  cuspidati,  at  the  eleventh  year;  the  seventh,  the 
second  molars,  at  the  twelfth  year ;  and  the  last,  the  third  molars  or 
wisdom  teeth,  at  a  period  varying  from  the  seventeenth  to  the  twenty- 
fifth  year — more  commonly,  however,  about  the  eighteenth  year. 

The  teeth,  in  their  eruption,  arrange  themselves  in  a  physiological 
regularity  in  the  arches  which  have  enlarged  for  their  accommoda- 
tion through  a  process  of  elon- 
gatory  and  interstitial  growth ;  ^*" 

if  development  and  functional 
harmony  have  not  been  inter- 
fered with,  the  fully-grown  or- 
gans are  found  occupying  in 
regular  relations  the  two  jaws-, 
yielding  perfect  occlusion  and 
articulation.  (See  Associate 
Lesions.) 

Articulation.  (See  Fig.  1.) — 
In  examining  the  articulated 
skull,  it  is  seen  that  the  six 
upper  front  teeth  close  over  and 
in  front  of  those  of  the  inferior 
jaw,  while  the  external  tubercles 
of  the  bicuspidati  and  molars  of  the  lower  jaw  lodge  in  the  sulci  be- 
tween the  external  and  internal  tubercles  of  those  of  the  upper  jaw ; 


First  and    second    dentition,   upper  and    lower 
maxillw. 


110  ORAL  DISEASES  AND  SURGERY. 

thus,  in  the  articulation,  placing  the  external  tubercles  of  the  upper 
teeth  external  to  the  outer  tubercles  of  the  lower.  The  central  incisor 
of  the  upper  jaw,  because  of  its  greater  width,  closes  not  only  over 
the  inferior  central,  but  overrides  the  lateral.  The  superior  lateral 
overrides  the  cuspid;  the  cuspid  its  fellow  and  the  first  premolar. 
The  premolars  override  their  fellows  and  the  anterior  third  of  the 
first  molar.  The  first  molar  opposes  the  anterior  third  of  the  second 
molar  and  the  posterior  two-thirds  of  the  first.  The  second  molar 
opposes  the  posterior  two-thirds  of  the  second  molar,  and  the  ante- 
rior third  of  the  wisdom  tooth.  The  wisdom  tooth  of  the  upper  jaw, 
being  smaller  than  that  of  the  lower,  finds  accommodation  in  antag- 
onism by  the  portion  of  its  fellow  left  unoccupied  by  the  second 
molar.  Thus  it  is  seen  that  no  two  teeth,  exclusively  oppose  each 
other, — an  admirable  provision,  which  not  only  guards  as  much  as 
seems  possible  against  loss  of  the  organs  from  lack  of  antagonism, 
but  secures  the  fullest  results  in  the  trituration  of  the  food. 


CHAPTER   YI. 

ASSOCIATIVE   LESIONS   OF   FIRST   DENTITION. 

Although  it  comes  not  strictly  within  the  province  of  a  work  on 
surgery  to  treat  of  the  associative  lesions  of  the  first  dentition,  yet 
it  would  seem  that  such  a  work  could  not  be  at  all  complete  without, 
at  least,  reasonable  reference  to  such  conditions. 

When  one  considers  the  delicate  and  susceptible  organism  of  an 
infant  human  being,  and  the  fact  of  its  usherance  into  a  world  where 
active  causes  of  disease  are  in  constant  antagonism  to  it,  he  is  very 
well  prepared  to  understand  that  in  the  influence  of  the  process  of 
dentition  must  necessarily  exist  a  powerful  predisposing  cause  in- 
viting to  attack,  and,  indeed,  opening  the  portals,  as  it  were,  to 
enemies  that  otherwise  might  have  passed  harmlessly  by. 

The  calculations  of  Dr.  Arbuthnot  that,  at  this  period,  one  in 
every  ten  children  has  its  life  destroyed  through  the  associative 
and  influenced  lesions  of  the  age,  may,  perhaps,  not  be  strictl}'-  in 
accordance  with  statistics  at  large;  but  the  mortality  is  so  alarm- 
ingly great  that,  to  the  general  practitioner,  no  subject  offers  in  its 
study  more  important  and  vital  interest^.  Professor  Camper  is 
authority  for  the  statement  that  out  of  5989  infants  admitted  into 
foundling-hospitals,  only  884  were  found  alive  at  the  end  of  the  fifth 
year. 

In  the  first  place,  we  have  to  remark  that  the  process  of  dentition, 
while  a  physiological  one,  is  yet,  like  that  of  utero-gestation,  one  of 
continuous  irritation.  Of  the  meaning  of  this  word  irritation, 
every  surgeon  and  every  physician  has  in  his  mind  quite  enough 
reminiscences.  Irritation,  then,  is  the  matter  of  consideration  in  all 
of  these  associative  lesions;  if  happily,  in  such  cases,  we  could 
exactly  appreciate  and  exactly  control  such  irritations,  we  should  of 
course  abort  or  resolve  the  results. 

It  is  not,  however,  by  any  means  to  be  esteemed  that  all  infantile 
diseases  are  influenced  by,  or  indeed  even  remotely  associated  with, 
dentition:  mistakes  of  such  nature  are  quite  too  frequently  made, 
and  infants  are  tortured,  and  in  many  cases  have  the  existing  dis- 

(111) 


112  ORAL  DISEASES  AND  SURGERY. 

ease  aggravated,  by  the  lancing  and  cutting  which  follow.  It  is 
very  true  that  irritation  from  this  cause  has  not  always  an  associ- 
ated external  local  manifestation ;  but  such  manifestation  is,  I  think, 
much  more  frequently  to  be  found  present  than  absent, — at  any  rate,  it 
should  alwaj's  have  its  full  share  in  the  diagnosis.  It  will  of  course  be 
taken  for  granted  that  dental  irritation  is  influenced  to  a  most  marked 
extent,  all  other  things  being  equal,  by  the  slowness  or  rapidity 
of  the  evolution  of  the  teeth.  Thus,  such  equality  existing,  we  would 
not  anticipate  from  the  eruption  of  a  single  tooth  the  trouble  of  five 
or  six,  and  such  a  difference  in  evolution  is  so  common  that  it  may  be 
said  of  some  children  that  they  cut  their  teeth  in  mass,  while  with 
others  it  is  a  process  of  the  greatest  regularity  and  harmony. 
Again,  the  physical  condition  and  age  of  the  child  are  matters  not 
without  much  significance.  A  delicate  infant  suffers  more,  as  a 
general  thing,  than  a  robust  one;  while  premature  dentitions  are  at- 
tended with  more  danger  than  late  ones.  In  taking  into  consideration 
the  influences  of  this  process,  we  are  not  to  forget  either  the  vary- 
ing degrees  of  susceptibility  manifested  in  different  individuals,  as 
thus  we  are  led  to  appreciate  the  fact  that  judgment  is  not  to  be 
founded  alone  on  the  extent  or  degree  of  local  manifestation.  Some 
children  are  preternaturally  susceptible  to  stimuli,  and  these  are 
not  at  all  necessarily  of  the  weak  and  feeble  class;  others,  on  the 
contrary,  are  so  obtuse,  even  from  earliest  age,  as  to  be  very  little 
influenced  by  any  ordinary  or  common  cause  of  irritation. 

To  the  experienced  physician,  the  appreciation  of  associated  or 
abstract  dental  irritation  should  not  be  a  matter  of  difficulty.  He 
sees  and  he  does  what  is  to  be  done, — what  only  can  be  done  ;  if  the 
treatment  fails,  the  fault  resides  not  in  the  practice.  In  the  first 
place,  to  understand  dental  irritation,  one  must  be  familiar  with 
dental  evolution  ;  this,  of  course,  is  the  understanding  of  the  physi- 
ology of  the  subject.  We  know  the  varying  periods  of  eruption, 
and  we  are  thus  at  once  led  ver}^  directly  in  our  researches.  If  we 
find  a  source  of  offense,  as  manifested  by  a  tumid,  congested  gum, 
we  have  only  to  pass  a  lancet  down  to  the  confined  tooth,  and, 
having  done  this,  may  expect  and  hope  for  relief  from  any  general 
trouble  which  has  been  engendered  by  the  just  liberated  organ.  If 
we  look  into  the  mouth,  and  see  no  manifestations  of  offense,  it  is 
generally  the  case  that  dentition  has  nothing  to  do  with  a  trouble 
which  may  have  influenced  the  search, — not  always,  however,  for  it 
has  been  inferred  that  dentition  may  be  a  source  of  reflected  trouble, 
while  itself  presenting  no  local  signs.     Still,  such  cases  are  very 


ASSOCIATIVE  LESIONS   OF  FIRST  DENTITION.     113 

rare,  and  when  existing  depend  on  great  rapidity  in  evolution,  either 
as  a  single  tooth  is  concerned  or  the  simultaneous  advancement  of 
a  number.  Many  teeth,  rapidly  advancing  at  the  same  time,  could 
very  well  be  esteemed  as  a  source  of  constitutional  offense,  not  only 
as  diverting  in  such  direction  'an  excess  of  the  vital  force,  but  also 
in  local  irritations  induced  in  neighboring  structures,  and  which 
might  not  at  all  be  evident  by  any  external  signs.  In  these  latter 
cases  the  physician  can  do  nothing  but  increase,  by  indicated  means, 
the  ability  of  the  system  to  endure  the  irritation  ;  such  means  being 
more  frequently  found  in  tonics  than  in  sedatives.  In  the  weak, 
strict  attention  is  to  be  given  to  diet,  to  exercise,  and  to  cleanliness. 
The  character  of  the  clothing  is  also  of  much  consequence.  If  the 
milk  of  the  mother  is  not  properly  nutritious,  other  means  are  to  be 
taken  to  nourish  the  child. 

In  cases  where  there  seems  simply  an  excess  of  irritability,  such 
susceptibility  is  to  be  lowered  by  the  withdrawal  of  everything  ca- 
pable of  fostering  it ;  this  will  pertain  to  the  lodgment  of  the  child, 
and  to  its  food,  drink,  clothing,  exercise,  etc.,  matters  which  would 
at  once  strike  the  observant  practitioner. 

Disturbance  provoked  in  the  alimentary  canal,  and  fever  induced 
through  the  process  of  teething,  when  existing  conjointly  with  acute 
disease,  of  whatever  character,  necessarily  aggravate  such  disease, 
and  increase  by  just  that  much  the  attending  discomfort  or  danger; 
hence  the  recognized  increased  mortality  in  the  exanthemata  occur- 
ring at  this  period. 

The  diseases,  if  they  may  be  so  called,  directly  associated  with 
and  dependent  on  abnormal  dentition,  and  having,  therefore,  neces- 
sarily their  cure  more  or  less  intimately  associated  with  the  correc- 
tion of  the  primary  lesion,  are — 

1.  Localized  Stomatitis. 

2.  Irritative  Fever. 

3.  Diarrhoea. 

4.  Spasms. 

5.  Eruptions  on  the  Skin,  especially  of  the  Scalp  and  Face. 

1.  Localized  Stomatitis. — The  first  indication  in  this  condition, 
dependent  on  advancing  tooth  eruption,  consists,  most  likely,  in  a 
sense  of  titillation  or  itching, — as,  before  any  local  sign  is  visible, 
the  child  is  found  disposed  to  rub  the  parts  with  anything  coming 
into  its  hands,  seeming  most  comfortable  when  biting  upon  hard 
substances.  Slavering  is  also  associated  with. this  stage.  After  a 
time,  tumefaction  of  the  gums  is  observed,  and  this  inflammatory 

8 


114  ORAL  DISEASES  AND  SURGERY. 

action  circumscribes  or  extends  itself  on  the  same  principle  as  the 
vaccine  areola, — that  is,  as  influenced  by  constitutional  or  local  cir- 
cumstances. If  several  teeth  are  attempting  eruption  at  the  same 
time,  and  these  are  situated  at  opposite  sides  of  the  cavity,  then  the 
probability  is  that  the  inflammation  will  be  a  diffused  one.  If,  on 
the  contrary,  the  irritation  is  confined  to  a  single  tooth,  and  there  is 
in  the  habits  of  the  child  no  particular  inflammatory  tendency,  then 
it  may  reasonably  be  anticipated  that  the  area  of  congestion  will  be 
very  circumscribed.  The  shape  and  extent  of  face  in  the  erupting 
tooth  have  not  seemed  to  me  to  have  as  much  to  do  with  the  amount 
of  irritation  as  one  would  naturally  infer  to  be  the  case.  I  have 
certainly  seen  quite  as  much  trouble  from  an  erupting  incisor  as  in 
the  case  of  a  four-cusped  molar.  Bad  and  degenerating  inflamma- 
tions are  always  associated  with  constitutional  conditions.  Thus, 
in  scrofulous  children  it  is  sometimes  the  case  that  a  semi-gangrenous 
ulceration  is  the  result  of  cutting  a  tootii  which  it  is  quite  troublesome 
enough  to  manage;  while  in  children  of  a  mercurio-syphilitic  cachexia 
such  a  condition  will  be  even  aggravated,  the  gums  and  continuity 
of  mucous  membrane  looking  as  if  it  was  impossible  to  keep  the 
parts  from  breaking  down  into  general  ulceration.  AVhen  tume- 
faction of  the  gum  is  dependent  on  tooth  eruption,  and  the  child  is 
of  healthy  condition,  a  certain  evidence  is  found  in  the  glistening 
character  of  the  swelling:  the  part  immediately  over  the  toother 
teeth  looks  stretched  and  feverish.  This  tense  look  is  nearly  always 
present,  and  may,  under  all  circumstances,  be  esteemed  an  indica- 
tion demanding  the  use  of  the  lancet.*  In  unhealthy  conditions 
this  glistening  is  not  commonly  present,  its  absence  being  dependent 
on  the  flaccid,  relaxed  condition  of  the  gum  tissue.  Here,  as  im- 
plied, the  congestion  is  of  more  diffused  character ;  the  part  and 
associate  parts  are  turgid  and  soft-looking.  You  esteem,  in  looking 
into  the  mouth,  that  scarification  would  be  of  service,  but  that  it  is 
demanded  for  a  sense  of  general  relief,  rather  than  for  a  strictly  acute 
local  condition.  Lancing  in  the  first  of  these  cases,  if  properly  per- 
formed, yields  an  almost  instantaneously  good  result ;  in  the  second, 
such  relief  is  gradual,  and  most  likely  inconsiderable.  In  the  first, 
it  is  all-sufficient  to  the  cure  ;  in  the  second,  the  constitutional  indi- 
cations are  soon  felt  to  be  of  much  more  consequence  than  any  local 
requirements. 

*  The  application  of  the  tincture  of  beHadonna  to  a  gum  thus  congested  is 
a  source  of  much  relief.  A  full  saturation  of  the  bromide  of  potassium  is 
also  an  agent  of  more  or  less  comfort. 


ASSOCIATIVE  LESIONS  OF  FIRST  DENTITION.     115 

To  lance  the  gurus  of  a  child,  let  the  surgeon  seat  himself  directly 
in  front  of  the  nurse,  the  height  of  the  knees  of  the  two  parties  cor- 
responding. Let  the  nurse  now  take  the  child  on  her  lap,  support- 
ing its  whole  body,  excepting  the  shoulders  and  head,  which  are  to 
rest  upon  the  knees  of  the  operator.  In  this  position  the  nurse  con- 
trols perfectly  the  legs  and  arms  of  the  infant,  while  the  surgeon  has 
complete  command  of  its  head,  and  can  examine  and  operate  upon 
its  mouth  at  his  convenience.  The  face  of  the  child  should  look 
toward  the  window,  or,  if  night  is  the  time  of  operation,  the  light  of 
a  candle  or  a  lamp  may  be  employed. 

A  tooth  should  be  lanced  in  consideration  of  its  shape.  Thus,  if 
it  be  any  of  the  anterior  six  teeth,  either  of  the  upper  or  lower  jaw 
a  single  incision  made  sufficiently  deep  to  feel  the  lancet  strike  upon 
the  enamel  is  all  that  is  required.  This  incision  should  be  made 
across  the  mouth,  or  on  the  line  of  the  cutting  edge  of  these  teeth. 
With  the  posterior  teeth,  the  crucial  form  of  incision  is  demanded  : 
such  form  will  alone  relieve  the  advancing  cusps,  and  afford  the  result 
desired. 

Concerning  hemorrhage,  it  has  not  been  my  experience  that  any 
special  danger  is  to  be  apprehended.  I  certainly  never  hesitated  to 
lance  the  gums  of  a  child  on  this  score,  and  never  met  with  a  case 
that  gave  me  any  particular  trouble.  In  ordinary  cases,  the  loss  of 
a  little  blood  is  rather  to  be  desired  than  otherwise;  while  if  a  hemor- 
rhagic diathesis  exists,  the  local  application  of  strong  alum-water  or 
of  bayberry -powder  will  generally  be  found  all-sufficient  for  its  con- 
trol. A  little  cobweb,  as  found  in  the  cellar,  wet  with  borax-water, 
and  then  dipped  in  bayberry-powder,  will  in  ninety  cases  out  of  the 
hundred  control  the  bleeding  when  laid  over  the  incision, — the  ap- 
plication to  be  secured  by  passing  over  it,  if  necessary,  one  layer  of 
a  delicate  roller. 

A  constitutional  medicament,  of  good  effect  in  these  cases,  will  be 
found  in  the  Erigeron  Canadense, — one  drop  of  the  tincture  to  be 
given  in  a  little  water,  each  minute,  until  the  bleeding  ceases,  or 
until  twenty  or  thirty  are  taken.  Opium  and  lead  act  very  happily 
in  combination.  The  dose  of  each  must  of  course  be  small.  A  very 
good  formula  is  as  follows  : 

B. — Pulveris  opii,  gr,  ^ ; 
Plumbi  acetatis,  gr.  j  ; 
Aqufje  rosiB,  giij. 
Sig.  Tablespoonful  to  be  taken  each  half-hour,  p.  r.  n. 


116  ORAL  DISEASES  AND  SURGERY. 

Touching  a  bleeding  gum  with  Monsel's  solutions,  or  with  nitrate 
of  silver,  is,  in  my  experience,  dangerous  practice.  The  only  alarm- 
ing cases  of  hemorrhage  I  have  ever  seen  have  been  the  results  of 
these  applications.  It  is  true  that  such  effects  may  rest  rather  with 
the  operator  than  with  the  agents ;  but  it  is  seldom  that  one  seems 
to  succeed  in  using  them  with  sufficient  cleverness  and  localization. 
They  are  certainly  much  more  apt  to  do  a  great  deal  of  harm  than 
an}^  reliable  good  ;  secondary  hemorrhages  are  common  to  them, 
and,  when  ensuing,  are  always  of  a  character  much  more  difficult  to 
manage  than  the  primary  trouble. 

Another  matter  in  this  connection  particularly  worthy  of  note,  is 
the  influence  on  the  hemorrhage  through  the  sticking  propensity  of 
infants.  This  is  to  be  obviated  by  passing  a  roll  of  rubber  or  other 
convenient  material  across  the  mouth,  and  so  confining  it  that,  while 
it  shall  not  fret  the  little  patient,  it  will  destroy  the  ability  to  make 
a  vacuum.  This  manipulation  is  very  simple  and  easy  of  accom- 
plishment. The  ordinary  soft  india-rubber  ring  may  be  cut  in  the 
middle ;  tie  a  piece  of  string  or  tape  to  each  end,  pass  the  rubber 
across  the  mouth,  and  fix  the  tapes  on  the  back  of  the  neck  ;  an  hour 
or  two  will  be  found  quite  sufficient  to  retain  the  apparatus  in  the 
mouth. 

Cases  of  localized  stomatitis,  having  association  with  the  strumous, 
scorbutic,  or  syphilitic  cachexia,  require,  as  suggested,  a  treatment 
external  to  the  cau.se  exciting  it;  the  child  must  be  built  up;  the 
inflammation  passing  quickly  into  an  adynamic  type  demands  for  its 
cure  stimulation  rather  than  depression  ;  or,  to  express  the  require- 
ments more  justly  and  explicitly,  a  local  treatment  must  be  quieting 
and  perhaps  refrigerating,  while  tonics,  combined  with  the  mineral 
acids,  will  be  required  constitutionally. 

A  child  eight  years  of  age,  of  marked  scrofulous  condition,  tissues 
relaxed,  abdomen  pendent,  was  presented  at  one  of  my  clinics,  suf- 
fering with  trouble  in  the  oral  cavity.  Making  an  examination,  the 
mucous  membrane  of  the  palatine  aspect  of  the  superior  jaw  was 
found  angry  and  uncomfortable-looking,  no  tension  at  any  point,  but 
the  whole  membrane  turgid,  and  yet  flaccid-looking.  In  searching 
for  the  cause  of  trouble,  the  age  of  the  patient  directed  a  first  atten- 
tion to  the  position  of  the  first  bicuspid  teeth,  the  lateral  incisors 
being  erupted  and  in  position ;  exploration  with  the  lancet — the 
deciduous  molars  had  been  removed  long  before — revealed  these 
teeth  on  either  side,  with  the  second  bicuspid  of  the  right  side  nearly 
ready  to  erupt.    The  ordinary  crucial  incisions  were  then  made.    In 


ASSOCIATIVE  LESIOXS   OF  FIRST  DENTITION.     117 

the  case  of  a  healthy  child,  this  would  have  been  all-sufficient;  with 
such  a  child,  however,  not  so.  Relief  to  some  extent  will  cer- 
tainly be  obtained  from  the  incision;  but  the  congestion  will  con- 
tinue, and  it  may  be  will  grow  worse,  the  parts  seeming  to  lack  the 
energy  necessary  to  the  restoration.  In  this  particular  case,  and 
which  is  here  noted  merely  as  a  type,  the  mouth  was  ordered  to  be 
washed  three  times  each  day  with  very  dilute  brandy  and  aromatic 
sulphuric  acid.  Internally,  lemonade  was  given  every  two  hours,  five 
drops  of  brandy  being  added  to  each  wineglassful.  Aromatic  sul- 
phuric acid  acts  very  happily  in  these  and  similar  cases,  or  nitro- 
muriatic  acid  may  be  administered  in  from  two-  to  five-drop  doses,  three 
or  four  times  a  day.  Iron,  combined  with  an  acid,  as  in  the  Ferri 
Chloridi  Tinctura.  is  a  most  admirable  medicine,  given  in  from  five- 
to  eight-drop  doses,  three  times  a  day.  It  is  found  also  not  unfre- 
quently  necessary  in  these  cases  to  bring  the  acid,  in  a  more  concen- 
trated form,  directly  to  bear  upon  some  obstinate  point  of  ulceration; 
this  is  done  very  readily  by  means  of  a  pine  stick.  Dip  the  point 
into  the  acid  used,  and  employ  concentrated  or  dilute  according  to 
the  seeming  requirements  of  the  case.  The  acid  nitrate  of  mercury 
so  applied  is  found  sometimes  to  act  very  happily,  or  deliquesced 
chloride  of  zinc  may  be  used.  The  zinc,  followed  by  a  brush  of  the 
officinal  tincture  of  iodine,  will  sometimes  induce  granulation  as  if 
by  magic ;  or  tincture  of  iodine  combined  with  creasote  may  be 
employed  with  every  hope  of  success. 

]n  syphilitic  stomatitis,  specific  treatment  must  be  conjoined  with 
the  supporting.  A  combination  that  I  use  with  very  satisfactory 
effect  is  as  follows  : 

R. — Hydrargyri  chloridi  corrosivi,  gr.  j; 
Potassii  iodldi,  3j  5 

Syrupi  ferri  pyrophosphatis,  ^iv.     M. 
Sig.  From  a  quarter  to  half  a  teaspoonful,  according  to  age,  three 
times  a  day. 

It  not  unfrequently  happens,  however,  that  a  treatment  which 
may  have  preceded  ours  has  been  too  free  in  the  exhibition  of  the 
mercurials ;  here  this  medicine  is  no  longer  to  be  used,  but,  con- 
joined with  the  supporting  treatment,  we  are  to  employ  the  chlorate 
of  potash: 


118  ORAL  DISEASES  AND   SURGEBY. 

R. — Potassas  chloratis,  ^ss  ; 
Aquse,  5viij.     M. 
S.  Teaspoonful,  internally,  four  to  six  times  a  day,  and  the  mouth 
to  be  washed  with  the  same,  ad  libitum. 

An  admirable  local  application  in  the  syphilitic  sore  mouth  and 
throat  is  made  by  adding-  to  a  six-ounce  infusion  of  white  oak  bark 
two  drachms  of  aromatic  sulphuric  acid  and  six  grains  of  nitrate  of 
silver. 

In  all  adynamic  conditions  of  childhood,  it  is,  I  presume,  a  com- 
mon experience  that  no  better  treatment  is  to  be  found  thau  lies  in 
the  observance  of  general  hygienic  laws.  The  food  must  be  nour- 
ishing, and  not  given  to  repletion.  Fresh  air  and  exercise  are 
necessities.  The  child  should  sleep  by  itself,  or,  what,  as  it  is  con- 
cerned, is  even  better,  it  might  sleep  with  some  young  person  of 
more  robust  and  healthy  condition.  The  daily  use  of  the  salt-sheet 
bath,  with  the  water  tepid  or  cold,  according  to  the  ability  of  the 
patient  to  bear,  is  an  invaluable  adjunct  to  restoration.  Throw  the 
wet  sheet  quickly  about  the  person  of  the  child,  and  rub  until  a 
fine  glowing  reaction  sets  in.  In  the  use  of  this  means,  however, 
close  attention  is  to  be  given  to  the  daily  result.  If  reaction  is  not 
secured,  but  the  child  grows  cold,  and  the  cutaneous  capillaries  con- 
tract unduly,  then  such  bath  is  to  be  discontinued ;  or  if  cold  water 
has  been  used,  it  must  be  modified,  even  perhaps  to  absolute  warm- 
ness,  A  good  plan  to  adopt  with  this  bath,  is  to  commence  with 
milk-warm  water  and  advance  by  gradations  to  cold. 

All  the  functions  of  a  child  of  scrofulous  or  syphilitic  condition 
are  to  be  carefully  watched.  If  the  bowels  are  habitually  cos- 
tive, as  is  frequently  the  case,  olive  oil  of  good  quality  may  be 
administered  q.  s.  This  oil  not  only  obviates  such  a  condition, 
but  acts  as  a  most  desirable  article  of  nutrition.  If  given  alone,  a 
teaspoonful  or  dessertspoonful,  each  day,  administered  at  any  con- 
venient period,  will  generally  be  found  sufficient, — and,  indeed,  in 
many  cases,  too  laxative.  If  the  child  is  of  an  age  to  take  the  oil 
mixed  with  other  food,  much  attention  to  the  quantity  employed 
will  not  be  found  of  special  consequence.  In  cases  where  the 
kidneys  fail  to  eliminate  with  sufficient  rapidity,  small  doses  of 
sweet  spirits  of  nitre  may  be  exhibited.  Buchu,  where  there  is 
undue  irritability  of  the  urinary  apparatus,  will  be  found  to  apply 
very  happily.  A  prescription  which  I  very  frequently  make  is  as 
follows  : 


ASSOCIATIVE   LESIONS   OF  FIRST  DENTITION.     119 

Take  of  buchu  one  ounce;  add  one  and  one-half  pints  of  hot 
water,  and  simmer  down  to  one  pint;  when  cold,  strain,  and  give  in 
teaspoonful  doses,  four  or  six  times  a  day,  p.  r.  n. 

Particular  attention  to  the  state  of  the  skin  is  also  demanded. 
This  tissue  should  feel  soft,  not  relaxed  ;  moist,  and  reasonably  oily; 
it  must  be  kept  very  cl^an,  but  not  washed  too  frequently  with  soap. 
Whisky  or  brandy,  where  stimulation  seems  indicated,  may  be  added 
to  the  water  with  which  a  child  is  bathed  ;  but  a  healthy  skin  is  to 
be  made  rather  from  within  outward,  than  from  without  inward — 
that  is  to  say,  a  skin  which  does  not  properly  perform  its  offices,  in- 
dicates, as  a  general  thing,  some  derangement  ulterior  to  itself,  so 
that  the  local  attention  implied  is  never  to  be  esteemed  but  as  adjunct 
treatment.  It  has  not  unfrequently  happened  to  me  to  observe  that 
a  stomatitis  having  apparently  a  local  signification  has  immediately 
disappeared  on  the  correction  of  a  trouble  existing  in  the  skin. 
This  is  markedly  seen  in  the  retrograde  exanthems. 

Angina  simplex,  simple  inflammation  of  the  fauces,  is  not  un- 
frequently dependent  on  irritations  existing  or  having  origin  in  the 
oral  cavity.  Here  the  trouble  is  one  of  continuity  of  structure,  and  its 
relief  is  found,  of  course,  in  the  cure  of  the  exciting  trouble.  Angina 
simplex,  or  the  extension  of  the  oral  inflammation,  is  generally  first 
made  evident  in  difficulty  of  swallowing.  Examination  reveals  the 
throat  red  and  congested,  the  degree  being  influenced  by  the  con- 
dition of  the  patient.  Sometimes  this  congestion  is  so  great  as  to 
make  the  act  of  deglutition  an  impossibility;  even  fluids  taken  into 
the  throat  will  be  ejected  through  the  nostrils.  The  uvula  oc- 
casionally will  be  enlarged  to  an  extent,  as  the  result  of  effusion  into 
its  cellular  structure,  which  seriously  endangers  the  respiration  of 
the  patient,  compelling,  indeed,  in  many  cases,  the  amputation  of 
the  organ.  In  some  instances  degenerating  aphthous  patches  (an- 
gina aphthosa)  appear  upon  various  parts  of  the  mucous  membrane  ; 
these  denote  that  the  inflammation  is  adynamic  in  its  type,  and  are, 
I  think,  always  a  matter  of  concern,  just,  indeed,  as  a  phagedenic 
chancre  is  a  cause  for  more  alarm  than  a  simple  sore,  implying 
a  degenerative  tendency  and  absence  of  vital  force.  An  aphthous 
ulcer  is  a  patch  of  varying  signification.  It  is  the  form  of  ulceration 
and  exudation  so  frequently  seen  in  weakly,  broken-down  women. 
The  niicroscope  insists  on  the  aphthous  exudate  as  a  fungous 
growth ;  it  has,  however,  as  yet  failed  in  designating  an  antidote. 
Angina  simplex,  it  has  been  remarked,  when  dependent  on  any  oral 


120  ORAL  DISEASES  AND  SURGERY. 

trouble,  may  be  expected  to  retire  upon  the  removal  of  the  immediate 
cause.  This,  however,  is  not  always  the  case,  as  is  witnessed  in  the 
adynamic  types,  or  in  children  of  very  full  or  sanguine  temperament. 
In  these  cases,  a  treatment  must  be  pursued  as  implied  in  the  indi- 
cations. If  the  continuance  of  such  inflammation  depends  on  a 
surcharged  condition  of  the  vessels,  general  or  local  depletion  will 
be  found  demanded.  Three  or  four  Swedish  leeches,  or  twice  as 
many  American,  may  be  put  upon  the  upper  part  of  the  throat;  the 
number  to  be  graduated  to  the  strength  of  the  patient  and  the 
urgency  of  the  case.  A  treatment  preliminary  to  this,  and  one 
which  in  my  own  practice  I  always  employ,  when  the  case  is  not 
especially  urgent,  consists  in  reducing  the  volume  of  blood,  by 
the  administration  either  of  diaphoretics  or  the  valine  cathartics. 
Epsom  salts,  a  teaspoonful  in  a  wineglass  of  water,  will  carry 
much  fluid  from  the  blood  of  a  young  child  ;  or  the  spirits  of  Min- 
dererus — covering  the  patient  warmly  until  diaphoresis  is  produced 
— given  in  teaspoonful  doses,  every  ten  minutes,  will  be  found  to 
sometimes  very  quickly  break  up  such  inflammations.  Hot  pedi- 
luvia  are  not  to  be  neglected  ;  the  feet  and  legs  of  the  little  patient, 
kept  in  hot  water  for  the  space  of  a  quarter  of  an  hour,  will,  in  very 
many  cases,  be  all-sufficient  for  a  cure.  A  less  speedy  but  fre- 
quently very  successful  way  of  treating  angina,  consists  in  divert- 
ing, as  it  were,  the  seat  of  irritation  ;  thus,  by  the  admmistration  of 
nitre  we  may  send  it  to  the  kidneys,  or  with  tartar  emetic  throw  it 
upon  the  skin. 

R. — Spiritus  ammonise  aromatici, 

Spiritus  setheris  nitrosi,  aa  ^ss.     M. 
S.  Give  from  five  drops  to  a  teaspoonful,  according  to  age,  every 
three  or  four  hours. 

The  ammonia  in  the  above  prescription  drives  the  congesting 
blood  forward,  while  the  nitre  directs  it  toward  the  kidneys. 

An  emetic  will  not  unfrequently  break  up  a  sthenic  sore  throat. 
In  the  case  of  children,  syrup  of  ipecacuanha  answers  every  purpose. 
It  may  be  given  in  doses  varying  from  a  half  to  a  full  teaspoonful, 
according  to  age,  every  ten  or  fifteen  minutes,  until  the  desired 
result  of  emesis  is  obtained. 

If,  conjoined  with  the  local  inflammation,  we  have  a  sympathizing 
by  the  system  at  large,  as  manifested  in  fever,  febrifuges  are  to  be 
employed.  The  following  combination  will  be  found  happily  adapted 
to  such  indications : 


ASSOCIATIVE  LESIONS  OF  FIRST  DENTITION.     121 

R. — Liquoris  potassse  citi*atis,  siij; 
Spiritus  ajtheris  nitrosi,  5ss  ; 
Pulveris  antimonii  et  potassae  tartratis, 
Morphise  acetatis,  aa  gr.  j.     M. 

Of  this  mixture  the  dose  for  aa  adult  would  be  a  dessertspoonful 
every  two  hours ;  for  an  infant  one  year  of  age,  from  five  to  eight 
drops  might  be  given,  being  diminished  or  increased  according  to 
efifect.     Overdoses  produce  sick  stomach. 

Diet. — This  should  of  course  be  light,  as  in  all  sthenic  inflamma- 
tions. The  child  may  be  limited  to  the  breast  alone  ;  or  if  age  or 
circumstances  will  not  permit  of  this,  gum-water,  or  other  light  and 
UDstimulating  food,  should  be  alone  employed — that  is  to  say, 
should  be  alone  employed  while  the  grade  of  the  inflammation  Is 
running  upward.  Ice-cream  is  an  admirable  food,  particularly  when 
eaten  slowly  and  continuously.  By  continuously,  however,  is  not 
meant  that  great  quantities  are  to  be  taken,  but  that  a  reasonable 
portion  be  made  to  last  as  long  as  possible.  Eaten  in  this  way,  it 
is  refrigerant  not  only  to  the  inflamed  part  over  which  it  necessarily 
passes,  but  to  the  system  at  large,  lowering  th^  heat  of  the  whole 
body,  and  thus  quieting  the  disturbed  circulation. 

Chronic  Angina. — Inflammation  of  the  fauces,  running  into  a 
chronic  condition,  in  children,  may  perhaps  always  be  considered  as 
depending  on  some  constitutional  predisposition.  In  these  cases 
the  glandular  bodies  seem  to  be  most  markedly  the  seat  of  trouble. 
Granulations  are  generally  prominent  over  the  mucous  membrane, 
this  tissue  being  covered  with  a  mucoid  or  muco-purulent  secretion. 
Ulcers  are  very  common,  and  not  unfrequently  are  of  such  degener- 
ative tendency  as  to  threaten  the  continuity  of  the  parts.  A  dis- 
agreeable association,  connected  nearly  always  with  a  neglected 
angina,  is  the  chronic  enlargement  of  the  tonsil  glands.  I  have 
been  compelled  to  operate  in  these  cases,  as  every  slight  cold  would 
so  swell  up  these  bodies  as  to  render  respiration  almost  as  difficult 
as  in  asthma.  I  have  just  now  under  treatment  a  little  girl,  in 
whom,  from  this  cause,  these  glands  are  so  enlarged  that  respiration 
during  sleep  is  accomplished  only  by  an  effort  that  it  is  absolutely 
painful  to  listen  to.  Of  course  the  case  is  curable  by  excision  or 
the  cauterant;  but  to  this  neither  parent  nor  child  can  be  brought  to 
submit.  The  sense  of  tickling  and  rawness  in  the  throat,  in  chronic 
angina,  is  another  source  of  discomfort;  the  patient  is  constantly 
kept  coughing  and   hawking.     This  is  induced    not  unfrequently 


122  ORAL   DISEASES  AND   SURGERY. 

through  the  dryness  of  the  membrane,  and  again  as  a  result  of  the 
irritating  nature  of  the  secretions,  or  it  may  be  dependent  on  ulcera- 
tion. From  whatever  cause  arising,  however,  I  have  never  found 
anything  better  adapted  to  its  temporary  relief  than  gum  arable  or 
the  jujube  troches  held  in  the  mouth  and  allowed  slowly  to  dissolve  ; 
or  a  gargle  compounded  as  follows  may  be  used  ad  libitum  : 

R. — Tincturse  iodinii  composites,  gtt.  xl ; 
Acidi  carbolici,  gtt.  vj  ; 
Glycerine,  3j ; 
Aqu^e,  svij.     M. 

Brushing  the  part  with  the  tincture  of  belladonna,  or  with  a 
saturated  solution  of  the  bromide  of  potassium,  is  sometimes  found 
to  abort  the  severity  in  these  cases  very  speedily.  Difficulty  in 
hearing  is  another  frequent  association  of  chronic  angina, — the  ex- 
planation being  found  in  the  inflammatory  thickening  of  the  Eusta- 
chian tube.  Pain  in  the  act  of  swallowing  is  the  result  of  a  lymph 
exudate  in  the  submucous  cellular  tissue.  This  it  is  which  gives  the 
irregular  thickening  so  observable  about  the  posterior  wall  of  the 
pharynx. 

Chronic  angina,  if  not  dependent  on  any  specific  constitutional 
conditions,  would  be  most  rationally  treated  by  stimulation,  local  or 
general,  or  both,  as  would  seem  to  be  indicated.  The  ordinary 
domestic  remedy  of  a  red-pepper  gargle,  if  judiciously  used,  not 
unfrequeutly  produces  a  speedy  cure.  Unhappih^  however,  domes- 
tic medication  is  too  apt  to  be  carried  to  excess,  a,ud  thus  adds  to, 
in  place  of  subverting,  a  disease.  If  a  true  uncomplicated  chronic 
angina  presents  in  a  child, — and  it  will  not  do  to  deny  that  such 
eases  may  exist, — let  the  patient  first  be  treated  with  a  lotion  com- 
pounded as  follows  : 

R. — Tincturae  capsici  compositse,  oSS  ; 
Aquae,  3viij.     M. 

If  a  few  applications  of  this  gargle  should  not  effect  a  change,  let 
nitrate  of  silver  be  added,  in  proportion  of  one-half  a  grain  to  the 
ounce.  If  even  this  should  not  result  in  the  desired  change,  then  it 
will  be  well  to  esteem  that  a  general  medication  is  indicated.  First 
we  set  about  to  correct  any  functional  disturbances  that  may  be 
present,  and  follow  such  corrections  with  tonics.  Muriated  tincture 
of  iron  is  an  admirable  medicine,  where  the  system  seems  to  require 


ASSOCIATIVE   LESIONS   OF  FIRST  DENTITION.     123 

building  up;  quinine,  in  the  majority  of  cases,  may  be  given  in  addi- 
tion, with  a  very  happy  effect. 

R. — TincturiB  ferri  chloridi,  5'U  5 
Quinise  sulphatis,  gr.  x.     M. 
S.  To  be  taken  in  from  three-  to  ten-drop  doses,  according  to  age, 
three  times  a  day. 

Where  treatment,  as  just  indicated,  shall  fail,  alterative  medica- 
ments of  the  various  classes  may  be  tried, — alum-water,  tincture 
of  iodine,  weak  dilutions  of  creasote,  acid  nitrate  of  mercury,  chloride 
of  zinc,  solutions  of  lead,  etc.  Constitutional  vices  must  receive 
a  full  share  of  attention.  I  have  presumed  to  imply  that  in  children 
affected  with  chronic  angina  the  cause  is  always  found  to  exist  in 
such  direction.  Scrofula  is  by  far  the  most  common  of  these  vices. 
A  scrofulous  child  is  liable  to  almost  any  description  of  physical  de- 
generation. Now,  scrofulous  degeneration  is  rather  a  difficult  thing 
to  describe,  the  conditions  being  so  diversified  and  varied.  A  child 
descended  from  consumptive  parents  is  degenerate, — it  is  not  amiss 
to  say  scrofulous.  A  scrofulous  child  has  not  necessarily  always  a 
special  distinctive  type  as  in  general  signification  is  hereafter  de- 
scribed. It  may,  for  example,  have  white,  delicate  skin,  tumid  abdo- 
men, non-compact,  pouting  lip,  and  the  languid,  listless  gait.  It 
may  have  every  belonging  of  the  most  marked  lymphatic  tempera- 
ment ;  or,  on  the  other  hand,  a  scrofulous  patient  may  look  as  if 
possessed  of  all  the  characters  of  a  vigorous  constitution.  I  do 
not  know  what  better  to  do,  in  cases  of  this  kind,  than  to  make  a 
general  observation  of  antecedent  and  present  conditions  and 
found  a  treatment  accordingly.  Syphilis,  it  has  been  inferred  by 
some  writers,  lies  closely,  or  it  may  be  in  the  distance,  as  the  root 
of  such  conditions;  but  if  this  should  be  the  case,  a  treatment  anti- 
syphilitic  is  not  necessarily  implied.  This  peculiar  vice  may  have 
lost  itself  in  a  general  degenerative  condition,  just  as  an  injury, 
which  has  of  itself  gotten  well,  may  yet  be  the  cause  of  broken 
health  and  physical  adversity, — just,  indeed,  as  phthisis  may  suc- 
ceed syphilis,  long  since  inferred  to  have  been  cured.  In  all  such 
cases  we  can  only  hope,  in  the  correction  of  ill  conditions  recognized 
as  existing,  to  find  the  good  Ave  require.  We  may  philosophize  and 
reason,  but  if  nothing  functionally  wrong  is  perceived,  we  must 
have  recourse  to  a  somewhat  empirical  treatment,  building,  as  we 
say,  the  patient  up.     lu  other  words,  there  are  no  specific  means  of 


124  ORAL  DISEASES  AND  SURGERY. 

cure ;  therefore  we  resort  to  such  general  tonics  as  experience  has 
demonstrated  to  be  useful.  Cod-liver  oil,  cream,  mixture  of  sperma- 
ceti and  milk,  preparations  of  iron,  infusions  or  tinctures  of  the  bitter 
barks,  as  the  Peruvian,  serpentaria,  gentian,  etc.,  are  medicines  to 
be  employed  in  these  cases. 

2.  Irritative  Fever. — Irritative  fever,  fever  from  the  irritation  of 
teething,  is  a  direction  of  infantile  trouble  ver\^  frequently  demand- 
ing the  attention  of  the  physician.  It  may  not  be  amiss,  for  the 
benefit  of  the  student,  to  recall  that  by  irritative  fever  we  mean 
fever  the  result  of  something  that  produces  overexcitement.  This, 
it  is  true,  would  also  be  a  definition  of  inflammatory  fever,  the  two 
conditions  being,  as  we  understand,  really  one  and  the  same,  except 
in  degree.  Now,  the  irritative  fever  of  dentition  is,  as  a  rule,  a 
rapid  fever — that  is,  it  appears  and  disappears  quickly;  the  lancing 
of  a  gum  causing  it  very  frequently  almost  instantly  to  vanish:  not 
always,  however,  for  it  can  readily  be  understood  that  such  a  dis- 
turbance of  the  functional  conditions  could  be  excited  as  to  make  a 
return  to  an  equilibrium  much  less  probable  than  production  of  some 
organic  change. 

All  febrile  conditions  in  children  of  a' sthenic  type  are  attended 
with  much  restlessness;  but  the  fever  of  dentition  is  markedly  so. 
Muscular  excitability  is  a  prominent  association ;  the  sleep  is  broken ; 
thirst  is  very  great;  the  appetite  is  impaired  and  irregular,  the  child 
taking  the  breast  rather  for  the  relief  obtained  from  the  moisture 
of  the  milk  than  from  desire  for  food ;  the  pulse  is  not  unfrequently 
driven  to  an  incredible  rapidity;  the  face  is  flushed  and  burning; 
the  eyes  are  congested  and  protruded.  Convulsions,  and  not  unfre- 
quently death,  mark  the  climax. 

The  disturbance  effected  in  the  system,  as  has  been  remarked, 
will  be  found  in  proportion  to  the  local  irritation,  and  the  age,  con- 
stitution, and  general  condition  of  the  patient.  The  marked  mo- 
bility existing  in  the  nervous  structure  of  infants  I'enders  the  brain 
peculiarly  susceptible;  it  is  therefore  a  most  common  association  to 
find  the  feverish  infant  flighty,  and  perhaps  entirely  out  of  its  head; 
while  if  febrile  disturbance,  consequent  upon  dentition,  supervenes 
when  other  diseases  are  in  progress,  such  diseases  will  be  commonly 
much  intensified. 

The  diagnosis  of  dental  irritative  fever  is  not  always  an  easy 
matter,  and  simply  because  the  fever  is  irritative,  and  not  inva- 
riably inflammator\' — that  is  to  say,  the  local  disturbance  is  con- 
fined to  the  vis  vitae,  and  does  not  involve,  to  a  perceptible  extent, 


ASSOCIATIVE  LESIOXS  OF  FIE  ST  DENTITIOX.     125 

the  local  vascular  system.  We  look  into  the  mouth,  but  see  no 
swelling  of  the  gums,  no  evidences  of  inflammation  ;  yet  the  trouble 
is  there,  and  it  may  be  that  it  is  only  by  incision  that  the  fever  is 
to  be  controlled;  the  diagnosis  must  therefore  necessarily  not 
unfrequently  be  of  a  differential  character.  To  aid  us  in  this, 
Ave  not  only  consider  the  absence  of  other  causes  of  irritation,  but 
we  have  a  marked  assistance  in  our  knowledge  of  the  varying 
periods  of  tooth  eruption,  and  of  the  causes  advancing  or  retarding 
such  evolution. 

Where  dental  evolution  is  inferred  to  be  the  cause  of  a  febrile 
manifestation,  and  incisions  do  not  seem  to  be  demanded,  we  are  to 
resort  to  ordinary  general  treatment.  Lemonade,  prepared  with 
crushed  ice,  is  a  most  grateful  and  refrigerating  febrifuge;  the  neu- 
tral mixture,  made  fresh,  by  simply  adding  the  carbonate  or  bicar- 
bonate of  potassa  to  lemon-juice,  is  another  excellent  medicine.  This 
addition  may  be  made  to  a  full  saturation.  Or  a  refrigerating  mix- 
ture, as  follows,  may  be  prescribed,  and  administered  pro  re  vata  in 
teaspoouful  doses: 

R. — Liquoris  potassse  citratis,  5iij  ; 
Potassii  bromidi,  5j  ; 
Aquae,  Sj. 

Much  relief  is  commonly  given  by  sponging  the  skin  when  it  is 
very  hot,  using  water  and  alcohol,  or  water  and  cologne,  or  water 
and  vinegar.  Bathing  the  wrists  in  cold  water  is  another  source  of 
great  comfort.  Bromide  of  potassium  alone  is  an  admirable  prepa- 
ration to  administer  in  febrile  conditions.  To  children  it  may  be 
given,  dissolved  in  strong,  ice-cold  lemonade,  in  doses  of  two  grains 
or  more  to  the  tablespoonful.  Tartar  emetic,  added  to  these  doses 
in  the  proportion  of  the  fortieth  of  a  grain  to  each,  assists  its  quiet- 
ing influence.  Where  the  pulse  is  much  excited,  and  the  infant  is  of 
sthenic  condition,  tincture  of  veratrum  viride  may  also  be  added,  one 
drop  to  each  dose;  in  the  use  of  this  last  agent,  however,  the  effect 
as  its  action  on  the  circulation  is  concerned  is  to  be  watched  Avith 
care.  Emetics  are  highly  valued  by  some.  Cathartics  may  also 
be  used  to  good  purpose,  the  sulphate  or  carbonate  of  magnesia 
being  employed,  as  preferred. 

When,  in  defiance  of  treatment,  a  fever  of  irritation  continues,  our 
efforts  are  to  be  directed  to  effects  that  may  be  produced  outside  of 
the  ordinarv  functional  disturbances.    The  extension  of  inflammation 


126  ORAL  DISEASES  AND   SURGERY. 

by  continuity,  where,  for  example,  severe  and  unyielding  inflamma- 
tion resulting  from  dentition  exists,  may  produce  pharyngitis,  paro- 
titis, bronchitis,  pneumonitis,  gastritis,  or  it  may  excite  to  take  on 
morbid  action  the  brain,  the  heart,  the  liver,  or,  indeed,  any  organ 
of  the  body.  When  such  sequelae  occur,  we  are  to  treat  the  parts 
involved,  as  in  any  common  inflammation,  just,  indeed,  as  we  have 
been  treating  the  unyielding  fever,  except  that  we  may  feel  the 
necessity  to  make  such  treatment  more  vigorous;  it  maybe  that 
under  such  circumstances  we  will  find  the  local  or  general  abstrac- 
tion of  blood  an  absolute  necessity. 

In  these  cases  it  is  not  to  be  forgotten,  however,  by  the  prac- 
titioner, that,  conjoined  with  the  original  cause  of  inflammation, 
some  other  may  exist ;  thus,  a  malarial  influence  may  have  been 
lying  in  abe3'ance,  and  needed  but  the  depression,  the  result  of  the 
dental  trouble,  to  allow  of  its  asserting  itself;  or  it  may  be  that 
some  half-corrected  tendency  to  congestion  is,  by  the  excitation, 
entirely  undone.  Such  associations  are  constantly  to  be  considered 
if  treatment  is  to  be  successful.  This  excitation  of  morbid  action  is 
well  demonstrated  in  the  association,  with  dentition,  of  diarrhoea 
and  the  cutaneous  eruptions;  while  the  treatment,  wherever  the 
secondary  irritation  shall  exhibit  itself,  is  recognized  to  have  a 
common  character. 

3.  Diarrhcea. — The  alimentary  mucous  membrane  being  con- 
tinuous from  the  mouth  to  the  anus,  it  will  be  at  once  recognized 
that  a  localized  inflammation  could  render  irritable  the  whole  tract. 
It  is  thus  that  diarrhoea,  or,  indeed,  more  commonly  all  the  symp- 
toms of  cholera  infantum,  associate  with  difficult  tooth  eruption,  and 
it  is  thus  that  to  cure  a  diarrhoea  or  an  attack  of  cholera  infantum 
we  have  so  frequently  only  to  cut  down  upon  a  certain  confined 
tooth  or  teeth.  I  am  led,  however,  to  infer  that  it  is  quite  too 
common  a  practice,  during  the  period  of  dentition,  to  ascribe  to  this 
process  not  only  every  diarrhcea,  but  the  numberless  other  functional 
irregularities  which  may  happen  to  occur  at  such  period.  Diar- 
rhoea, or  this  combined  with  vomiting,  has  many  causes  apart  from 
the  influences  of  tooth  eruption. 

The  stomach  of  an  infant  may  be  likened  to  an  enlarged  portion 
of  a  common  tube,  and  not  only  this,  but  it  is  a  vertical,  or  almost 
vertical,  tube  ;  hence  a  child  overfed  needs  only  to  be  inverted  to 
have  the  milk  run  from  the  orifice  of  the  tube. 

Again,  the  mucous  membrane  of  the  intestines  of  an  infant  is 
tender  and  susceptible  ;  excess  of  food,  or  food  not  easy  of  digestion, 


II 


ASSOCrATIVE  LESIOXS  OF  FIRST  DENTITION.     127 

irritates  this  menil)rane,  and,  by  the  relationship  of  tissue,  excites  to 
action  the  middle  coat  of  the  tube,  yielding  discharge  or  diarrhoea. 
Crapulous  diarrhoea  may  thus  be  somewhat  continuous,  for  the 
reason  that,  unassisted,  the  contractions  may  fail  to  relieve  the  canal 
of  the  source  of  offense,  and  thus  their  continued  efforts  keep  up 
the  continued  discharges.  Worms  irritating  the  canal  are  the 
frequent  cause  of  diarrhoea.  In  hot  weather  we  generally  have 
an  increase  in  diarrhoea  cases;  and  not  only  is  the  irritation  thus 
induced  not  limited  to  the  intestinal  tract  proper,  but  the  liver  as 
markedly  sympathizes ;  hence  the  frequency  in  these  months  of 
cholera  infantum,  the  excess  of  bile  being  thrown  both  ways.  En- 
teritis, from  follicular  ulceration  in  typhoid  conditions,  may  induce 
and  keep  up  a  diarrhoea  in  a  child  as  it  does  in  an  adult.  Tabes 
raesenterica  is  a  cause  of  diarrhoea  in  the  scrofulous  infant.  Syphilis 
may  ulcerate  and  irritate  the  intestinal  tract,  just  as  we  so  frequently 
see  such  irritation  in  the  mouth.  These  allusions  are  sufficient  to 
remind  us  that  diarrhoea  is  not  a  disease,  but  only  a  symptom,  and 
that,  whether  occurring  in  the  dentitional  or  any  other  period,  it 
may  have,  as  its  provocative,  a  great  variety  of  sources  or  lesions. 
When  a  diarrhoea  depends  on  a  dental  origin  it  is  perhaps  always 
a  condition  of  vascular  perversion,  and  is  entirely  direct  in  its 
nature  ;  the  erupting  tooth  or  teeth  inflame  the  mucous  membrane 
of  the  mouth,  and,  by  the  continuity  of  tissue,  the  irritability  ex- 
pends itself  over  the  intestinal  portion  of  the  structure.  It  is  well  to 
remember  that  in  diarrhoea  of  this  character  there  is  much  or  little 
nmcin,  according  to  the  state  of  the  inflammation,  and  much  casting 
off  of  epithelial  scales ;  but  there  is,  of  course,  nothing  diagnostic 
in  such  phenomena,  because  of  their  not  being  peculiar  to  a  par- 
ticular form  or  character  of  inflammation.  We  are  to  look  at  the 
mouth  and  at  the  throat ;  if  there  is  a  local  condition  of  irritation 
and  inflammation,  and  if  the  vascular  derangement  extends  as  far 
as  we  can  follow  it,  we  have  reasonable  grounds  for  inferring  that 
in  the  teeth  resides  the  origin  of  the  trouble,  particularly  if,  having 
examined  the  system  at  large,  we  fail  to  discover  other  lesions. 
I  do  not  desire,  however,  to  be  understood  as  asserting  that  it 
is  only  in  this  way  we  have  dental  diarrhoea,  for  I  well  know 
there  is  another  way,  and  that  is  through  the  second  of  the  legs 
of  Bichat's  tripod.  I  very  well  know  that  there  is  an  influenced 
innervation,  and  that,  if  the  bowels  of  an  infant  are  weaker  than 
its  lungs  or  its  brain,  such  deranged  innervation  will  there  expend 
itself.     I  have  seen   the   diarrhoea  of  such   deranged   innervation 


128  ORAL   DISEASES  AhW   SURGERY. 

relieved  almost  instantly  by  an  incision  into  a  tooth-cyst,  and  yet 
there  was  no  redness,  no  swelling,  nor  any  other  evidence  of  local  ex- 
citability. These  cases  are,  however,  rare,  and  have  their  analogues 
in  the  reflex  spinal  irritations.  The  diagnosis  must  necessarily  be 
somewhat  differential  in  character ;  yet,  where  a  case  is  at  all  ob- 
scure and  the  circumstances  are  urgent,  it  is  commendable  practice  to 
make  incisions  over  the  positions  of  teeth  whose  periods  of  eruption 
correspond  most  nearly  with  the  time  of  operation. 

It  is  very  well,  however,  and  indeed  necessary,  to  remember  that 
a  mucous  membrane  may  be  inflamed,  in  varying  localities,  without 
having  intermediate  sanguineous  disturbance.  Thus  a  stomatitis 
and  an  enteritis  might  be  present  at  the  same  moment;  the  one  de- 
pending on  local  dental  disturbance,  the  other  upon  a  cause  or 
causes  of  entireh^  dissimilar  nature.  Now,  in  a  case  of  this  kind, 
having  associative  diarrhoea,  it  will  plainly  enough  be  seen  that 
any  treatment  directed  to  the  stomatitis  would  not  (except  as  a 
similarity  Jn  practice  might  pertain  to  both  troubles)  affect  the 
enteritis.  To  recognize  these  cases,  antecedent  conditions  must  be 
inquired  into.  Colds  or  atmospheric  vicissitudes  will,  most  fre- 
quently perhaps,  be  found  an  explanation  of  the  disturbances.  The 
cutaneous  circulation,  as  a  result  of  some  injudicious  exposure,  has 
been  depi'essed,  and  thus  the  enteritis  has  been  forced  upon  a  part 
having  the  least  ability  to  resist  the  inrolling  wave.  In  some  in- 
fants, restless  and  nervous  in  their  natures,  a  predisposition  to  enteric 
irritation  seems  to  be  inborn  ;  the  slightest  disturbance  reacts  in  this 
way.  It  may  not  be  that  diarrhoea  is  the  result,  but  the  trouble 
exhibits  itself  in  some  evident  wa}^ 

The  milk  of  a  nurse  is  occasionally  the  source  of  a  diarrhoea. 
Infusoria  and  crystalline  substances  will  be  found  frequently,  on 
examination,  in  such  milk.  Here  a  cure  would  be  obtained  only  by 
a  change  from  such  diet  to  one  which  would  be  healthy  or  uormal, 
— good  cow's  milk,  diluted  or  pure,  according  to  the  age  of  the 
infant,  being  the  best  substitute.  Other  causes  of  diarrhoea,  to  be 
considered  in  connection  with  a  supposed  but  doubtful  dental  source, 
are  debility;  hepatic  derangements,  interfering  with  the  venous 
circulation  ;  an  increased  peristaltic  motion  through  mental  emotions, 
as  anger  or  fright;  a  rheumatic  or  scrofulous  diathesis;  malarial 
influence,  etc. 

Diarrhoea  from  dental  irritation,  if  inflammatory  by  the  continuity 
of  relationship  in  the  membrane,  generally  demands  the  lancet  alone 
for  its  cure  ;  the  operator  should  free  the  advancing  tooth  or  teeth. 


ASSOCIATIVE  LESIONS   OF  FIRST  DENTITION.     129 

If,  however,  on  the  removal  of  such  cause,  the  effect  does  not  sub- 
side, the  invoked  and  persistent  irritability  is  to  be  treated  on  such 
principles  as  commend  themselves.  Sweet  oil  and  paregoric,  admin- 
istered internally,  I  have  found  to  act  very  happily.  To  each  tea- 
spoonful  of  the  oil  add  from  five  to  twenty  drops  of  the  opiate, 
according  to  the  age  of  the  little  patient.  Heating  applications  to 
the  abdomen  are  very  useful ;  for  example,  a  sinapism  made  as 
follows : 

Flour,  ^ss; 

Mustard,  5j ; 

Ginger,  5ij ; 

Black  pepper,  5ss. 
Mix  these  together  with  a  little  vinegar,  and  retain  against  the 
skin  until  the  part  is  well  reddened.     It  is  not  at  all  necessary  to 
blister  the  surface. 

Another  and  perhaps  a  more  comfortable  mode  of  treatment  is  to 
give  small  doses  of  Dover's  powder,  or,  what  I  prefer,  the  liquor 
potassse  citratis,  in  conjunction  with  minute  doses  of  tartar  emetic. 

R, — Spiritus  tetheris  nitrosi,  sss  ; 
Liquoris  potassce  citratis,  5[\ ; 
Antimonii  et  potassae  tartratis,  gr.  ^.     M. 
Give  in  ten-  to  fifteen-drop  doses  each  two  hours. 
This  combination  serves  to  direct  the  irritability  to  the  surface, 
and,  by  a  relief  thus  afforded  the  affected  part,  not  unfrequently 
yields  a  cure. 

If  the  inflammation  has  anything  of  a  sluggish  or  passive  char- 
acter, the  spirit  of  Mindererus  will  act  happily,  Half-teaspoonful 
doses  each  two  or  three  hours  should  be  given. 

Diarrhoea  from  dental  irritation,  not  inflammatory  in  character,  is 
to  be  treated  in  consideration  of  its  nervous  relation  ;  and  just  here 
is  the  condition  in  which  the  bromide  of  potassium  acts  most  satis- 
factorily. It  may  be  given  in  five-grain  doses,  dissolved  in  water, 
or,  if  the  practitioner  does  not  like  to  commence  in  the  infant  with 
such  a  dose,  he  may  try  if  less  will  answer  his  purpose,  and  increase 
pro  re  nata.  Less  than  five  grains,  however,  I  do  not  think  will  do 
much  good,  unless,  indeed,  the  child  is  very  young.  Spirit  of  Minde- 
rerus, sweet  spirit  of  nitre,  and  the  camphorated  tincture  of  opium 
also  act  most  satisfactorily  in  these  cases.     They  may  be  given  in 

9 


130  ORAL  DISEASES  AND  SURGERY. 

such  proportions  as  seem  indicated.  An  ordinary  prescription  would 
be  about  as  follows: 

R. — Spiritus  Mindereri,  sij; 

Spiritus  aetheris  nitrosi,  5ss; 
Tincturae  opii  campboratse,  5ij-     M. 
S.  About  twenty-five  drops  each  two  hours. 

The  following  combination  is  a  valuable  one,  when  other  sources 
of  irritation,  not  perhaps  thoroughly  appreciated,  exist  in  conjunc- 
tion with  the  dental  trouble  : 

R. — Hydrargyri  chloridi  mitis,  gr.  ij ; 
Pulveris  opii, 

Pulveris  ipecacuanhas,  aa  gr.  j  ; 
Magnesiae  carbonatis,  gr.  xij. 
Divide  into  eight  powders,  and  administer  one  after  each  opera- 
tion, if  profuse ;  otherwise,  each  two,  three,  or  four  hours,  according 
to  judgment. 

4.  Spasnis. — To  appreciate  the  cause  and  condition  of  spasms  and 
convulsions  in  early  childhood,  whether  influenced  or  not  by  the 
excitements  of  dentition,  one  has  but  to  consider  the  restless  mo- 
bility of  the  cerebro-spinal  system  at  such  age.  If,  at  an  early 
period  of  life,  we  examine  the  gray  matter  of  the  spinal  cord,  Ave  are 
struck  with  its  development  when  compared  with  the  similar  sub- 
stance in  the  cerebral  portion  of  the  encephalic  mass.  To  express 
ourselves  differently,  the  ganglion  of  excito-motor  or  reflex  action  we 
find  to  be  much  in  excess  in  its  development,  and  not  only  so,  but 
sensitive  and  susceptible,  as  its  offices  are  concerned,  to  the  last 
degree, — a  result  most  likely  of  the  necessity  for  the  motion  of  growth 
and  development  existing  in  the  members  of  a  child  ;  such  a  sj'stem 
may  be  compared  to  a  tensely-strung  instrument,  responding  to  the 
slightest  touch. 

The  difference  between  a  regular  and  irregular  motion  is  the  dif- 
ference between  an  ability  or  disability  of  the  cerebellar  gray  matter 
to  perform  its  functions  of  co-ordination ;  the  difference  between  a 
co-ordinated  and  an  irregular  motion  is  the  difference  of  spasm ;  and 
if  we  carry  it  to  the  disability  of  the  cerebral  mass  to  influence,  it  is 
the  difference  of  convulsion. 

Spasm,  then,  may  be  defined  to  be  irritation,  direct  or  indirect,  of 


ASSOCIATIVE  LESIONS  OF  FIRST  DENTITION.     131 

the  spinal  cord  or  of  its  terminal  outshoots  or  nerves.  This  founda- 
tion-principle appreciated,  the  further  consideration  of  the  subject 
is  not  at  all  difficult.  Very  true  it  is,  that  there  may  be  causes  of 
disturbance  that  we  cannot  discover ;  but  the  results,  and  the  mean- 
ing of  them,  are  not  thereby  rendered  obscure  :  it  would  be  only  the 
cure  that  would  be  delayed  or  denied. 

We  are  prepared,  then,  to  recognize  in  what  way  dental  evolution 
is  a  cause  of  spasm  :  it  is  precisely  as  it  is  a  cause  of  diarrhoea,  as  it 
is  a  cause  of  fever;  but  the  reflected  irritation  in  the  latter  case 
expends  itself  on  the  muscular  system  rather  than  upon  the  mucous 
or  vascular.  The  cure,  or  the  mode  of  cure,  suggests  itself:  first,  we 
are  to  remove  the  condition  of  irritation  ;  second,  if  the  parts  do  not 
quickly  soothe  and  quiet  themselves,  we  are  to  help  them.  To  meet 
the  first  indication  we  simply  lance  the  gums.  1  do  not  think  that 
in  these  cases  we  are  to  be  influenced  entirely  by  local  manifesta- 
tions of  congestion:  we  should  cut  freely  down  upon  teeth  whose 
periods  of  eruption  suggest  them  as  being  the  source  of  offense. 
Take  a  pledget  of  cotton,  and,  saturating  it  with  a  solution  of 
atropine  sulphas,  thrust  it,  by  means  of  some  delicate  instrument, 
into  the  cut  you  have  made.  This  is  quite  equal,  at  least  as 
such  a  case  is  concerned,  to  the  more  common  subcutaneous 
injection,  and  tends  to  quiet  the  disturbed  nerve  filaments.  Or 
the  bromide  of  potassium,  as  before  suggested,  may  be  used;  or, 
drying  the  gum  with  a  napkin,  the  smallest  possible  quantity  of  the 
extract  of  belladonna  may  be  rubbed  over  the  part,  or  it  may  be 
touched  with  a  point  of  nitrate  of  silver.  If  yet  the  spasms  should 
persist,  some  general  effect  on  the  nervous  system  at  large  must  be 
secured.  Tinctures  of  valerian  and  gentian  in  equal  parts,  given  in 
ten-drop  doses,  repeated  pro  re  nata,  will  sometimes  act  most  satis- 
factorily. If  this  should  not  answer,  the  bromide  of  potassium, 
internally,  may  be  employed.  The  bromide,  cantharides,  and  cam- 
phor, as  recommended  by  Dr.  Chambers  in  epilepsy,  constitute  an 
admirable  combination : 

B. — Potassii  broraidi,  gr.  iij ; 

Tincturse  cantharidis,  gtt.  iij ; 
Misturfe  camphorae,  gtt.  x.     M. 
Sig.  Repeat  this  in  a  little  water,  p.  r.  n. 

If,  after  proper  trial  of  the  above, — say  a  few  hours, — the  irrita- 
bility fails  to  be  subdued,  the  inference  will  be  that  our  diagnosis 


132  ORAL  DISEASES  AND  SURGERY. 

has  been  a  mistake,  and  that  dentition  has  not  been  wholly,  at  least, 
in  fault. 

At  this  point  we  see  the  necessity  of  glancing  at  other  causes  of 
irritation  which  may  exist.  Many  children  incline  to  nervous  dis- 
turbance from  anaemia ;  this  we  know  to  be  a  quite  common  cause 
of  such  derangements.  An  anemic  condition  might  not  of  itself,  in 
a  special  case,  induce  spasm,  but  assisted  by  a  conjunction  with  a 
second  irritant,  the  two  together  could  excite  to  the  condition ;  and 
one  removed,  the  other  could  very  well  resist  a  curative  agent.  A 
glance  here  shows  us  why  the  sedative  has  not  effected  the  cure ; 
let  us  add  iron  to  our  prescription,  and  a  very  few  more  days  will 
give  a  different  result.  Perhaps  the  condition  of  a  child  is  just  the 
reverse ;  instead  of  being  anemic,  it  is  plethoric.  Give  to  this  child 
repeated  doses  of  some  suitable  saline  mixture,  and  conjoin  with 
the  bromide  of  potassium  quarter-grain  doses  of  calomel;  or,  if  you 
do  not  wish  thus  to  medicate,  diet  closely  for  a  few  days, — give 
nothing  but  the  breast,  and  this  only  in  the  daytime ;  or,  if  the 
period  is  that  of  second  dentition,  deprive  it  of  all  but  vegetable 
food,  with  water  for  drink ;  a  cure  w^ould  most  likely  follow  such 
treatment.  Lack  of  good,  fresh,  pure  air;  unwholesome  food; 
deficient  or  improper  clothing ;  sleeping  with  debilitated  persons ; 
the  milk  of  the  nurse  ;  articles  of  food  not  easy  of  digestion  ;  hepatic 
derangements ;  worms  in  the  alimentary  canal ;  influences  passed 
from  mother  to  infant;  and  numberless  similar  conditions,  are  ex- 
citing and  predisposing  causes  of  spasm  and  convulsions;  and  all 
demand,  in  every  case,  their  share  of  consideration,  if  we  are  to  be 
successful  in  treatment. 

Spasm  resulting  from  the  congestion  of  nerve  centres,  however 
induced,  is  not  unfrequently  tonic  in  its  character  ;  the  child  may 
lose  all  consciousness ;  it  passes  into  the  state  that  we  call  convul- 
sion. In  these  cases  results  must  be  obtained  immediately ;  we  mu.st 
relieve  the  overburdened  part.  How  ?  By  derivation.  Try  first  a 
hot  foot-bath ;  let  it  be  as  hot  as  the  skin  will  bear.  Inclose  the 
steam  of  the  water  so  that  it  shall  envelop  all  of  the  child  but  its 
head  ;  compel  it,  if  possible,  to  take  teaspoonful  doses  of  the  spiritus 
Mindereri.  The  steam,  or  the  steam  and  mixture  in  conjunction, 
will  soon  compel  profuse  perspiration,  and  thus  secure  a  double 
derivation.  Such  treatment  will,  most  likely,  relieve  the  congested 
part;  at  least  it  has  generally  proved  reliable  in  my  hands.  If  it 
should  not  answ^er  the  intention,  then  a  vein  may  be  opened,  or 
leeches  may  be  applied.    The  opening  of  a  vein  in  such  cases  I  have 


ASSOCIATIVE  LESIONS   OF  FIRST  DENTITION.     133 

never  had  occasion  to  resort  to,  but  it  is  good  practice,  and  is  recom- 
mended by  the  best  writers.  The  pediluvia  and  derivation  by 
perspiration,  I  thinlc,  however,  will  be  found  reliable.  If,  after  con- 
sciousness is  restored,  the  pulse  continues  rapid,  with  fullness,  give 
one-drop  doses  of  the  tincture  of  veratrum  viride,  or  i*elax  the  S3's- 
tem  generally  by  doses  of  tincture  of  lobelia  or  the  syrup  of  ipecacu- 
anha. Ten  drops  of  either  of  these  medicines,  repeated  as  indicated, 
will  very  well  answer  the  purpose.  Keep  the  child  now  cool,  and 
guard  against  every  source  of  discomfort. 

An  instructive  and  suggestive  case  where  epilepsy  had  its  irritant 
in  dental  irritation  is  described  in  the  Medical  Record  by  Dr.  Na- 
thaniel Field.  The  paper  states  that  a  small  boy,  about  five  years 
of  age,  while  apparently  in  good  health,  was  suddenly  attacked  with 
an  epileptic  fit,  from  which  he  soon  recovered.  The  parents  were 
much  surprised  at  the  occurrence,  and  were  unable  to  account  for  it. 
About  two  weeks  afterward  he  had  another  strong  convulsion,  last- 
ing several  minutes;  but  it  passed  off  without  any  constitutional 
disturbance.  No  cause  for  the  attack  was  discovered  by  the  relator 
or  other  practitioners.  In  a  day  or  two  the  fits  returned,  and  were 
repeated  at  short  intervals  for  about  ten  days,  during  which  time  it 
is  asserted  that  he  must  have  had  a  thousand.  Every  resource  in 
the  power  of  Dr.  Field  was  exhausted,  and  three  eminent  medical 
professors  examined  the  child  from  the  crown  of  his  head  to  the  soles 
of  his  feet,  but  no  local  irritation  was  discovered.  After  carefully 
watching  the  commencement  of  the  paroxysms,  he  observed  that  the 
muscles  of  the  left  side  of  the  face  invariably  began  to  twitch  on  the 
recurrence  of  a  fit.  After  a  convulsion  had  passed  off,  and  while  in 
a  state  of  unconsciousness,  he  raised  the  upper  lip,  and  found  the 
corona  of  the  second  canine  tooth,  instead  of  having  caused  by  a 
just  relation  the  absorption  of  the  root  of  the  deciduous  tooth,  had 
passed  behind  it,  and  had  forced  it  through  the  alveolus  and  gum 
into  the  lip.  The  gum  was  now  slit  vertically  and  the  old  tooth 
removed.  In  less  than  an  hour  the  convulsions  began  to  subside, 
and  before  the  day  was  over  they  had  entirely  gone,  and  never 
again  appeared. 

Passive  congestions  are  sometimes  a  cause  of  infantile  spasms ; 
these  are  not  difficult  to  distinguish  from  the  acute  or  active  con- 
ditions, the  languor  and  sluggishness  markedly  contrasting  with 
the  turgidity  and  fullness.  Again,  they  are  distinguished  from  the 
active  state  in  their  results,  these  being  not  immediate,  but  medi- 
ate.    Passive  congestions  depend  on  some  obstruction  in  the  circu- 


134  ORAL  DISEASES  AND  SUBGERY. 

latory  apparatus,  and  are,  perhaps,  more  frequently  associated  with 
the  chylopoietic  than  with  any  other  system.  Stagnations  may  also 
occur  as  a  result  of  some  interference  with  the  respiratory  office,  or 
they  may  be  the  result  of  the  action  of  some  directly  sedative  poison. 
Wherever  and  however  they  exist,  they  are  to  be  removed,  if  pos- 
sible, by  meeting  and  combating  the  cause,  which,  of  course,  is  the 
philosophy  of  cure. 

"In  cases  of  pure  irritation,"  writes  Dr.  Wood,  "besides  removing 
the  cause,  it  is  proper  to  diminish  the  nervous  susceptibility  and  to 
control  the  cerebral  irritation  by  diffusing  the  excitement  over  the 
whole  system.  To  meet  the  first  indication,  narcotics  may  be  em- 
ployed ;  and  none  is  more  efficacious  than  opium,  which,  to  diminish 
its  stimulant  influence,  may  be  combined  in  some  instances  with 
ipecacuanha.  Hyoscyamus,  lactucarium,  or  conium  may  be  substi- 
tuted, if  on  any  account  thought  preferable.  But  before  resorting 
to  these  remedies,  the  practitioner  must  be  very  sure  of  his  grounds. 
He  must  be  quite  convinced  that  it  is  nervous  irritation,  and  not 
active  congestion  of  the  brain,  that  he  has  to  encounter.  The  second 
indication,  above  alluded  to,  is  to  be  fulfilled  by  antispasmodics, 
administered  by  the  mouth,  the  rectum,  or  the  skin,  and  by  the  use 
of  tonics,  of  which  the  metallics  are-deemed  most  efficient.  Of  these 
the  oxide  of  zinc  has  perhaps  enjoyed  most  reputation,  though  the 
chalybeates  should  be  preferred  in  anemic  cases.  Should  the 
digestion  be  impaired,  and  the  system  at  large  feeble,  the  simple 
bitters  or  quinia  might  be  preferable  to  the  metallic  tonics.  These 
remedies  may  often  be  combined  in  the  same  prescription.  Thus, 
opium  or  hyoscyamus,  assafetida,  and  either  oxide  of  zinc,  carbonate 
of  iron,  sulphate  of  quinia,  or  extract  of  gentian  or  quassia,  may  very 
properly  go  together.  The  cold  or  shower-bath,  cautiously  used, 
may  also  serve  to  strengthen  the  nervous  system.  Fresh  air  and 
nutritious  diet  of  easy  digestion  are  important.  Any  derangement 
in  the  hepatic  secretions  should  be  carefully  observed,  and  treated 
with  minute  doses  of  calomel,  blue  pill,  or  mercury  with  chalk. 
When  the  disease  .depends  on  intestinal  spasm,  great  advantage 
will  often  accrue  from  the  use  of  laudanum,  with  assafetida  or  spirits 
of  ammonia  by  the  mouth,  the  injection  of  musk  into  the  rectum,  the 
application  of  a  mustard  cataplasm,  or  blister  over  the  abdomen  ; 
and  if,  as  often  happens,  the  bowels  are  distended  with  flatus,  from 
the  introduction  of  a  catheter  into  the  colon,  and  drawing  off  the  air 
by  means  of  a  syringe.  Should  the  disappearance  of  an  eruption 
have  preceded  the  convulsions,  efforts  should  be  made  to  restore  it 


ASSOCIATIVE  LESIONS  OF  FIRST  DENTITION.     135 

by  friction  with  croton  oil  or  other  active  irritant.  In  urgent  cases 
a  blister  might  be  produced,  by  means  of  a  strong  solution  of  am- 
monia, on  the  surface  previously  affected. 

"  In  frequently  recurring  convulsions,  resisting  other  measures, 
and  threatening  life,  the  practitioner  would  be  justified  in  resorting 
to  the  inhalation  of  chloroform,  which  will  often  quickly  quiet  the 
spasms,  and,  if  reapplied  with  each  return,  may  obviate  the  danger 
until  the  tendency  is  past.  It  has  the  advantage,  moreover,  over 
other  narcotics,  of  not  congesting  the  cerebral  centres,,  though  the 
danger  of  fatal  prostration  from  its  use  must  not  be  forgotten.* 

"  Even  when  asphyxia  or  apparent  death  may  have  resulted  from 
the  convulsions,  hope  should  not  be  abandoned ;  but  efforts  should 
be  made  by  artificial  respiration  to  restore  the  functions  of  the  lungs, 
and  consequently  that  of  the  heart." 

Finally,  on  this  subject,  I  may  direct  attention  to  the  connection 
between  the  troubles  we  are  considering  and  the  predispositions  of 
an  hereditary  nature,  so  often  found  in  association.  When  these 
deteriorative  conditions  exist,  it  is  a  necessity  for  success  in  treat- 
ment that  we  consider  and  combat  them. 

5.  Eruptions. — That  the  skin  of  childhood  should  be  the  subject 
of  irritative  changes  is  certainly  only  what  is  to  be  expected,  and 
that  variations  in  condition  do  most  frequently  occur  is  as  true  as 
that  they  are  thus  expected. 

Certain  general  considerations  of  the  subject  give  us,  I  think,  the 
key-note.  Thus,  in  the  beginning,  a  momentary  thought  directed 
to  the  great  change  which  must  result  in  the  passage  from  intra-  to 
extra-uterine  life,  would  naturally  lead  to  the  anticipation  of  a  cuta- 
neous hyperemic  condition  at  once  to  be  developed.  In  intra-uterine 
life  we  not  only  have  the  delicate  and  susceptible  skin  lubricated 
with  the  soft,  bland  smegma,  but  pressure  on  any  and  every  part  is 
jealously  guarded  against  by  the  surrounding  amniotic  fluid.  A 
single  minute,  frequently,  and  the  most  irritative  changes  occur  : 
the  waters  pass  away,  the  uterus  crowds  and  presses  upon  every 
part  of  the  child,  while  the  outside  world,  still  less  considerate, 
receives  it  on  its  birth,  its  atmosphere  stimulating  and  irritating,  its 
rough  points  jagging  and  abrading,  while  unnecessary  and  too  fre- 
quently ill-advised  appliances  and  applications  add  to  the  common 
discomfort. 

Cutaneous  hyperaemia — erythema,  as  it  is  generally  called — is  a 

*  It  is  found  safer  to  combine  with  it  u  portion  of  sulphuric  ether. 


136  ORAL  DISEASES  AND  SUBGERY. 

child's  primary  skia  trouble.  Such  an  erythema  is  certainly  nothing 
more  nor  less  than  the  variegated  blush  of  an  overstimulated  circu- 
lation. Perhaps  if  the  smegma  were  left  undisturbed  for  a  few 
hours,  just  as  nature  smeared  it  ov^erthe  body,  or  until  the  skin  had 
become  somewhat  accustomed  to  its  new  atmosphere,  such  hyper- 
semia  would  be  avoided  ;  but  as  such  excitability  seems  to  do  no 
immediate  harm  to  the  child,  neither  nurse  nor  mother,  I  imagine, 
would  be  found  satisfied  with  such  an  arrangement.  But  does  this 
hypersemia  do  no  harm  ?  Does  it  not  provoke  an  excitability  in  the 
skin  which  would  be  better  absent?  Certainly  children  are  most 
susceptible  to  cutaneous  impressions,  as  witnessed  not  only  in  colds 
so  easily  taken,  but  by  the  variety  of  local  manifestations,  to  the 
relief  of  which  the  practitioner  is  so  frequently  called.  Dental  irri- 
tations pertain  to  these  troubles  only  as  they  act  as  excitants  to  the 
existing  predisposition,  or  as  they  keep  up  an  excitability  which 
overmasters  the  corrective  force  natural  to  the  vis  vitae. 

Hyperfemia  running  into  an  excess  is  inflammation.  Inflammation 
of  the  skin  finds  a  primary  expression  in  the  term  Dermatitis.  A 
dermatitis  has  secondary  signification,  as  it  presents  peculiarities 
which  lead  us  to  look  for  reasons  for  such  expressions.  Thus,  one 
inflammation  in  the  skin  is  a  simi51e  sthenic  increased  vascularity, 
having  the  phenomena  of  redness,  heat,  pain,  and  swelling.  A 
second  is  not  regular  and  honest  in  its  expressions,  but  throws  out 
claw-like  expansions,  and  looks  dusky  and  threatening,  throwing^  to 
the  surface,  here  and  there,  blebs  of  serum.  We  distinguish  this 
second  from  the  first  by  the  subterm  erysipelas,  or  erysipelatous 
inflammation.  Then  we  have  an  inflammation  which  presents  the 
peculiarity  of  studding  the  face  of  the  skin  with  pustules,  and  this 
derangement  we  distinguish  by  the  term  pustulas  or  pustular  inflam- 
mation. Another  form  covers  the  inflamed  surface  with  vesicles ; 
another  throws  out  groups  of  nodules, — papular;  another  circum- 
scribes its  redness  to  patches, — rashes  ;  another  presents  raised  or 
elevated  patches, — urticaria,  etc.  All  have  alike  the  primary  sig- 
nification of  a  perverted  circulation,  but  differ  in  presenting  dis- 
tinctive phenomena,  these  marking  differences  in  local  or  constitu- 
tional circumstances. 

That  dental  irritation  develops  or  creates  the  distinctive  features 
in  a  skin  disease  is  sheer  nonsense.  All  that  such  irritation  can 
have  to  do  with  the  matter  is  that  it  exhausts  the  system,  just  as  any 
pain  exhausts  and  tires  us,  and  reduces,  as  remarked,  the  ability  of 
the  vital  force  to  guard  or  protect  itself  against  an  enemy  or  enemies 


ASSOCIATIVE  LESIONS  OF  FIRST  DENTITION.     187 

in  waiting  at  the  threshold.     It  does  not  make  the  enemy,  it  only 
lets  him  in  by  weakening  the  bars. 

That  a  skin  disease  is  thus  introduced,  and  continued  in  an  ability 
to  resist  applied  medication,  is  true  beyond  the  shadow  of  a  doubt ; 
and  it  is  for  such  a  reason  that  the  consideration  of  dental  irritation, 
in  connection  with  infantile  skin  diseases,  is  most  important ;  and 
yet  this  study,  as  the  evolution  of  the  teeth  is  concerned,  differs  in 
no  wise  from  its  stud}'"  in  relation  to  stomatitis,  diarrhoea,  or  spasm, 
as  certainly  any  intelligent  mind  must  at  once  appreciate.  It  does 
differ,  however,  as  far  as  a  collateral  treatment  is  concerned,  and 
such  treatment  implies  the  study  of  skin  diseases,  as  in  works  on 
Dermatology  the  subject  is  presented.  It  comes  within  our  prov- 
ince here,  however,  simply  to  state  some  generalizations  in  such  a 
direction, — an  idea,  if  the  reader  pleases,  as  to  the  mode  which  such 
an  investigation  might  be  entered  upon  to  compel  it  more  readily  to 
yield  to  us  its  secrets. 

A  thousand  complex  scientific  terms  would  scarcely  exhaust  the 
vocabulary  of  the  dermatologist  of  the  signification  he  has  for  the 
varieties    and    modifications  of  pathological    skin   phases.     These 
diversified  conditions,  however,  are  found  to  revolve  around  eight 
centres.     The  centre  of  each  is  to  be  esteemed  the  nucleus  or  pith 
of  the  divisions ;  the  subdivisions   are  but   radii   of  the  common 
substance. 
All  skin  diseases  belong  to  one  of  eight  orders: 
1st.  Pimples. 
2d.  Scales. 
3d.  Rashes. 
4th.  Bullae. 
5th.  Pustules. 
6th.  "Vesicles. 
7th.  Tubercles. 
8th.   Spots. 
1.  Pimples — Papulae. — Small  and  pointed  elevations  of  the  cuticle, 
with  an  inflamed  base — very  seldom  containing  fluid,  seldom  sup- 
purating, and  commonly  resolving  as  scurf. 

Three  primary  divisions  of  papules  are  made:  strophulus,  lichen, 
and  prurigo. 

Secondary  dixnaions. — Strophulus  intertinctus. 

S.  albidus,  S.  confertus,  S.  volaticus,  S.  candidus. 
Lichen  simplex,  L.  pilaris,  L.  circumscriptus. 


138  ORAL  DISEASES  AND   SURGERF. 

L.  agrius,  L.  livldus,  L.  tropicus. 
Prurigo  mitis,  P.  formicans,  P.  senilis. 
P.  pudendi  muliebris. 

2.  Scales — Scaly  Diseases — Squamae. — Scales  or  laminae  form 
upon  the  skin.  Scales  are  of  various  forms, — in  some  cases,  as  in 
pityriasis,  resembling  a  scurf;  in  other  cases,  as  in  ichthyosis,  being 
broad  and  flattened,  and  bearing  likeness  to  fish-scales.  To  mark 
the  various  prominent  differences,  four  varieties  are  enumerated : 
Psoriasis,  Lepra,  Pityriasis,  Ichthyosis. 

Subdivisio7is. — Lepra  vulgaris,  L.  alphoides,  L.  nigricans. 
Psoriasis  guttata,  P.  diffusa,  P.  gyrata. 
P.  inveterata. 

Pityriasis  capitis,  P.  rubra,  P.  versicolor,  P.  nigra. 
Ichthyosis  simplex,  I.  cornea. 

3.  Rashes — Exanthemata. — Irregular,  variously  figured  patches, 
appearing  on  various  parts  of  the  body,  leaving  interstices  of  a 
natural  color,  and  terminating  in  exfoliations  of  the  cuticle.  The 
designation  is  generally  limited  to  efflorescences  originating  in  fevers, 
as  for  example  measles  and  scarlet  fever. 

Bateman,  however,  includes,  and  perhaps  more  philosophically, 
Erythema,  Urticaria,  and  Purpura  in  the  division. 

The  first  division  is,  then,  according  to  Bateman,  Rubeola,  Scarla- 
tina, Urticaria,  Purpura,  Erythema. 

Subdivisions. — Rubeola  vulgaris.  Scarlatina  simplex. 

S.  anginosa,  S.  maligna,  Urticaria  febrilis,  U.  evanida. 

TJ.  persistans,  U.  conferta,  U.  subcutanea. 

U.  tuberosa.  Purpura  simplex,  P.  hsemorrhagica. 

P.  urticans,  P.  senilis,  P.  contagiosa,  Erythema  laeve. 

E.  papulatum,  E.  tuberculatum,  E.  nodosum. 

4.  Bullee. — A  condition  in  which  effusion  occurs  on  the  true  skin, 
separating  the  cuticle  in  the  form  of  blebs  or  blisters.  An  effusion 
developed  by  a  blister  comes  justly  in  its  consideration  under  this 
head,  for  it  is  surely  not  less  a  bleb  because  a  blister  has  pro- 
duced it.  The  difference  between  such  a  bleb  and  one  resultant  from 
an  erysipelatous  inflammation  is  that  one  has  strictly  a  traumatic 
signification,  while  the  second  is  a  systemic  offense.  Blebs  or  bull« 
have  three  primary  classifications:  Erysipelas,  Pemphigus,  Pom- 
pholyx. 

The  subdivisions  are  into  Erysipelas  phlegmonodes,  E.  cedema- 
todes,  E.  gangraenosum,  E.  erraticum,  Pompholyx  benignus,  P.  dinu- 
turus,  P.  solitarius. 


ASSOCIATIVE  LESIONS  OF  FIRST  DENTITION.     139 

5.  Pustules — Pustulse. — An  inflammation  of  the  skin,  resulting  in 
the  formation  of  purulent  matter,  which  accommodates  itself  by 
throwing  up  little  circumscribed  tumors.  Whether  one  or  many  of 
these  pustules  rise  on  a  common  inflamed  base  depends  on  the 
fundamental  or  exciting*  cause;  and  because  the  conditions  which 
produce  pustular  inflammation  vary,  so  have  we  various  names  by 
which  to  distinguish  and  appreciate  these  causes.  Five  primary 
pustular  inflammations  exist :  Impetigo,  Porrigo,  Ecthyma,  Variola, 
Scabies. 

The  subdivisions  are  numerous,  depending  on  peculiarity  of  fea- 
tures. Impetigo  figurata,  I.  sparsa,  I.  erysipelatodes,  I.  scabida,  I. 
rodens,  Porrigo  larvalis,  P.  furfurans,  P.  lupiuosa,  P.  scutulata,  P. 
decalvans,  P.  favosa,  Ecthyma  vulgare,  E.  luridum,  E.  cachecticum, 
Variola,  Scabies  papuliformis,  S.  lymphatica,  S.  purulenta,  S. 
cachectica. 

6.  Vesiculse — Vesicles. — Vesicles  differ  from  pustules  in  con- 
taining lymph — they  look  like  little  water  pimples,  although  it  is 
very  frequently  the  case  that  the  contained  lymph  is  quite  opaque: 
the  end  of  a  vesicle  is  by  scurf  or  scab.  There  are  seven  primary 
varieties  :  Varicella,  Vaccinia,  Herpes,  Rupia,  Miliaria,  Eczema, 
Aphtha. 

The  subdivisions  are  Varicella  lenticulus,  V.  conoidge,  V.  globate, 
Herpes  phlyctsenodes,  H.  zoster,  H.  circinatus,  H.  labialis,  H.  prae- 
putialis,  H.  iris,  Rupia  simplex,  R.  prominens,  R.  escharotica, 
Eczema  solare,  E.  impetiginodes,  E.  rubrum,  Aphtha  lactautium,  A. 
adultorum,  A.  angiuosa. 

1.  Tubercula — Tubercles. — These  are  small,  hard,  circumscribed 
tumors — they  may  be  fixed  in  a  state  of  integrity,  or  they  may  be 
degenerative.  There  are  eight  kinds  of  these  tumors — or,  to  express 
it  differently,  there  are  eight  distinctive  differences:  Phyma,  Ver- 
ruca, Molluscum,  Vitiligo,  Acne,  Sycosis,  Lupus,  Elephantiasis, 
Frambcesia. 

Among  these,  subdivisions  seem  only  necessary  with  acne  and 
sycosis.  Thus,  there  are  three  peculiarities  in  acne,  Avhich  are 
marked  by  the  terms  Simplex,  Indurata,  Rosacea.  In  sycosis. 
Sycosis  menti,  and  S.  capillitii,  designating  the  location  of  the 
tubercles. 

8.  Macula — Spot — Mother-Mark — Freckles  or  EpUelis — Nasvus. 

These  eight  classifications,  after  Bateman,  with  his  subdivisions, 
make  out  of  skin  diseases  all  that  concerns  a  present  consideration 


140  OJiAL  DISEASES  AND  SURGERY. 

of  them.  It  is  for  the  student  to  comprehend  the  primary  divisions, 
as  their  pathological  differences  are  concerned ;  the  radii,  or  subdivi- 
sions, will  be  found  to  take  care  of  themselves.  Without  an  under- 
standing of  the  general  subject  one  could  scarcely  expect  to  appre- 
ciate any  accidental  or  positive  dental  relations.  The  subdivisions 
will  be  remarked,  on  examination,  to  be  simply  as  family  surnames 
distinguishing  one  child  from  another ;  it  is  true,  of  course,  that 
there  are  peculiarities  of  character,  just  as  each  child  is  peculiar, 
and  by  such  peculiarities  are  these  modifications'  on  the  primary 
condition  named.  Now,  it  is  not  by  any  means  common  to  asso- 
ciate all  these  conditions  with  dental  irritations  ;  yet  it  is  certainly 
true  that  any  one  of  them  may  have  such  association:  therefore,  if 
the  student  would  understand  one  he  must  understand  all. 


CHAPTER    VIL 

ANOMALIES   OF    SECOND   DENTITION  AND   THEIR   srRGICAL  RELATIONS, 

Understanding  and  appreciating  the  characteristics  and  relations 
of  a  normal  dentition,  we  are  prepared  to  pass  to  the  consideration 
of  abnormal  or  pathological  conditions.  Such  conditions  may  be 
justly  grouped  under  the  head  of  anomalies. 

Anomalies  in  second  dentition  may  be  classed  under  seven  heads: 

1st.  Teeth  common  to  the  age,  but  erupting  external  or  internal 
to  the  arch. 

2d.  Teeth  denied  space  in  the  arch,  because  of  natural  or  surgical 
interference  with  the  process  of  maxillary  enlargement. 

3d.  Germs  developing  in  positions  where  their  product  must 
remain  encysted. 

4th.  The  production  of  supernumerary  teeth. 

5th.  Third  dentitions. 

6th.  Teeth  the  periodontea  of  whose  fangs  are  in  association 
with  the  periosteum  of  the  sinus  maxillare. 

7th.  Germs  with  heterogeneous  development. 

These  seven  conditions,  then,  because  they  differ  from  a  just  or 
normal  dental  evolution,  we  call  anomalies. 

Anomaly  First. — A  tooth  external  or  internal  to  the  alveolar 
arch  not  unfrequently  gives  origin  to  an  ulcer  or  locates  epithelioma. 
Yet  close  as  is  this  primary  to  the  secondary  lesion,  and  evident  as 
such  relationship  would  seem  to  be,  I  have  known  ulcers  of  the 
tongue,  lips,  and  cheeks  treated  for  months — of  course,  without  suc- 
cess— where  it  has  never  seemed  to  strike  the  practitioner  that  the 
tooth  could  have  any  association  with  the  disease  ;  indeed,  in  one 
case,  where  the  patient  was  remotely  connected  to  myself,  death  was 
the  result  of  a  cancer  located  in  the  cheek  from  this  very  anomaly. 
A  second  case,  having  a  fatal  termination,  has  occurred  in  my  own 
practice,  epithelioma  of  the  cheek  having  been  located  through  the 
irritating  influence  of  a  wisdom  tooth  out  of  position,  and  which 
seems  to  have  been  entirely  overlooked. 

(141) 


142  ORAL  DISEASES  AND   SURGERY. 

Note. — Even  where  there  is  excess  of  room,  the  permanent  teeth 
not  unfrequently  erupt  irregularly ;  indeed,  this  applies  so  directly 
to  the  inferior  incisors,  that  it  may  almost  be  said  to  be  the  rule 
rather  than  the  exception.  Unless,  however,  specially  indicated,  it 
is  the  best  practice  to  leave  them  to  nature;  they  will  almost  always 
be  found  to  come  right  of  themselves.  I  would  be  understood  as 
classing  them  with  the  anomalies  only  as  derangement  is  marked 
and  permanent. 

Anomaly  Second. —  Teeth  denied  sjw.ce  in  the  arch.  This  anomaly 
has  perhaps  the  largest  associative  pathological  connection. 

I  have  remarked  that  this  lesion,  if  we  may  term  it  such,  is  more 
frequently  the  fault  of  the  surgeon  than  of  nature.  If,  for  one  mo- 
ment, we  refer  to  the  physiological  relations  existing  between  the 
first  and  second  dentures,  we  may  find  that  it  is  within  our  power 
to  prevent  the  many  ills  that  follow  so  frequently  in  this  train,  and 
simply  by  doing  little,  or,  more  commonly,  nothing. 

The  deciduous  dental  arch  is  filled,  as  we  are  all  aw^are,  com- 
pletely by  its  ten  teeth.  The  second  or  permanent  set  is  to  com- 
prise in  number  sixteen,  and  each  tooth  certainly  quite  as  large 
again  as  its  predecessor.  This  increase  in  number  and  size  of  the 
teeth,  it  is  evident,  must  be  provided  for  in  an  enlargement  of  the 
alveolar  arch.  This  provision  is  always  attempted  by  nature  in  the 
process  described  by  the  physiologist  as  the  elongatory. 

I  will  illustrate  this  process  of  maxillary  enlargement  by  con- 
sidering the  ten  milk  teeth  as  so  many  wedges  placed  in  a  springy 
arch.  This  arch  it  is  designed  to  lengthen  by  additions  to  either 
end.  If,  now,  these  wedges  should  be  removed  before  others  were 
ready  to  take  their  place,  it  is  evident  that  the  elongation,  being 
made  at  the  ends,  would,  to  a  greater  or  less  extent,  be  counter- 
balanced by  the  springing  together  of  the  parts  at  the  sites  of  the 
removed  wedges.  The  process  of  maxillary,  or  rather  alveolar, 
absorption,  is  truly  represented  by  this  retraction  of  an  arch.  In 
proportion  to  the  number  of  deciduous  teeth  removed  prematurely, 
will  be  the  curtailment  in  size  of  the  arch,  at  least  of  its  alveolar 
face. 

Let  us,  then,  look  at  the  results  of  such  abridgment, — approximal 
caries  of  the  teeth,  periosteal  troubles,  trismus,  odontocele,  necrosis, 
the  violent  inflammations  attendant  on  the  development  of  the  dentes 
sapientiae,  etc. 

Note. — If  there  is  a  pathological  Pandora's  box,  it  is  certainly  the 
lesion  of  an  overcrowded  maxillary  arch. 


ANOMALIES  OF  SECOND   DENTITION.  143 

Such  condition  is  made  evident  to  the  practitioner  the  moment 
he  looks  into  the  mouth  of  his  patient:  the  teeth  are  jammed  into 
the  most  uncomfortable-looking  positions  ;  the  deformity,  however, 
mostly  existing  in  the  front  of  the  mouth, — either  the  central  in- 
cisors override,  or  the  laterals  are  thrown  back,  or  otherwise  the 
cuspidati  take  the  tusk  position,  standing  out  prominently  from  the 
arch,  the  bicuspidati  occupying  too  anterior  a  location,  approxi- 
mating, indeed,  not  unfrequently  with  the  lateral  incisors. 

Treatment. — To  abort  the  ill  consequences  of  such  a  contracted 
arch,  extract  at  as  early  a  period  as  possible  the  first  bicuspidati  of 
either  side.  This  very  simple  operation  will  frequently  not  only 
secure  against  secondary  lesions,  but  will  occasionally  correct  the 
most  annoying  deformities.  Let  it  be  remembered,  however,  by  the 
practitioner  who  prefers  prophylactic  to  operative  surgery,  that  on 
his  treatment  of  the  deciduous  mouth  depends,  in  a  measure,  the 
health  and  comfort  of  the  adult. 

If  I  am  asked  what  is  to  be  done  with  the  deciduous  aching 
tooth,  I  may  answer  that  it  should  have  been  filled  on  the  first 
appearance  of  decay.  This  is  a  matter  which  no  parent  can  afford 
ever  to  neglect.  In  the  armamentum  of  the  oral  surgeon  are  plastic- 
materials,  easy  and  painless  of  introduction,  which  can  be  entirely 
depended  on  to  perform  the  service  required  of  them. 

Equal  parts  of  chloroform  and  tincture  of  aconite,  applied  to  an 
aching  nerve  on  a  delicate  pellet  of  cotton,  will  sometimes 
instantaneously  relieve  this  form  of  toothache.  Another  admir- 
able application  is  the  atropias  sulphas,  dissolved  in  water,  in 
the  proportion  of  six  grains  to  the  ounce ;  such  a  preparation, 
while  very  effective,  is  to  be  used,  however,  with  reasonable 
care. 

An  exposed  pulp  in  the  deciduous  tooth  is,  however,  so  constantly 
subject  to  irritation,  that  every  indication  calls  for  its  destruction. 
The  necessity  is  unfortunate,  but  the  demands  are  persistent,  and 
the  removal  of  the  part  seems  the  lesser  of  two  evils,  between  which 
the  practitioner  is  compelled  to  choose.  The  application  of  arsenic, 
however,  to  such  an  exposed  pulp  has  come  to  strike  the  experienced 
as  questionable,  and,  as  it  is  not  a  necessity,  it  will  be  found  best 
perhaps  to  restrict  the  use  of  this  agent  to  the  permanent  teeth.  A 
deciduous  pulp  may  be  destroyed  by  touching  it  a  few  times  with  a 
fully  saturated  tincture  of  iodine,  or  with  either  of  the  Monsel's  solu- 
tions of  iron.   (See  chapter  on  Odontalgia.) 

Arsenical   applications  are,  however,   frequently  employed,   but 


144  ORAL  DISEASES  AND   SURGERY. 

unless  a  practitioner  is  vqvj  conversant  with  the  physiolog-ical  change 
that  occurs  in  the  fangs  of  these  teeth,  he  had  better  not  I'isk  this 
means ;  if,  however,  he  feels  prepared  to  employ  such  an  escharotic, 
he  can  prepare  no  formula  better  than  the  following: 

R. — Acidi  arseniosi, 

Morphise  acetatis,  aa  gr.  x ; 
Creasoti,  q.  s.  to  make  a  thick  paste. 

This  is  a  paste  quite  universally  employed  for  destroying  the 
pulps  of  adult  teeth.  To  apply  it  to  the  milk  tooth,  take  a  piece  not 
larger  than  a  pin's  head,  and,  dropping  it  lightly  into  the  cavity, 
cover  loosely  with  cotton  ;  the  part  is  washed  out  with  warm  water 
after  four  or  five  hours.  I  would  not  leave  such  a  preparation  in  a 
deciduous  tooth  over  five  hours ;  and  if  absorption  of  the  fang  had 
advanced  to  any  extent,  even  one  hour  might  be  too  long.  Employ 
it  fearlessly  in  the  adult  mouth,  only  remembering  that  you  deal 
with  arsenic ;  but  with  the  child  too  much  caution  cannot  be 
exercised. 

The  central  incisors  of  the  deciduous  set  of  teeth  should  (a  normal 
life  continuing)  last  until  the  seventh  year;  the  laterals  until  the 
eighth  ;  the  first  deciduous  molar  until  the  ninth  year;  the  second 
until  the  tenth  ;  the  deciduous  cuspid  until  the  eleventh  ;  and  let  it 
be  remembered  that  the  most  posterior  molar  teeth  that  are  in  the 
mouth  at  the  sixth  year  are  the  first  permanent  molars,  and  that 
these  teeth  get  their  place  in  the  jaw  without  displacing  any  of  the 
deciduous. 

For  an  account  of  some  of  these  secondary  lesions,  together  with 
treatment,  see  future  pages. 

Anomaly  Third. — This  anomaly  is  remarked  by  examination  of 
the  classes  of  teeth  erupted.  Teeth  all  erupt  in  pairs,  so  that  one 
is  not  likely  to  be  deceived.  The  anomaly  is  not  unfrequeutly  the 
result  of  interference  with  the  development  of  the  germ  of  the  perma- 
nent through  non-absorption  of  the  root  or  roots  of  the  deciduous 
teeth. 

Example. — A  deciduous  central  incisor  erupts — as  the  rule — 
about  the  seventh  month,  and  is  succeeded  by  the  permanent  at  the 
seventh  year.  Now  the  physiological  relation  existing  between  the 
two  teeth  is  as  follows.  At  the  time  when  the  deciduous  has  attained 
its  fullest  development  the  germ  of  the  permanent  is  at  its  apex, 
(See  Fig.  52.)     Retrograde  metamorphosis  now  commences  in  the 


ANOMALIES   OF  SECOND   DENTITION.  145 

fang  of  the  deciduous,  while,  in  an  inverse  ratio,  the  development 
of  the  permanent  advances.  It  sometimes  happens,  however,  that 
no  process  is  set  up  for  the  taking  away  of  these  deciduous  fangs, 
and,  as  a  consequence,  the  permanent  are  compelled  to  make  alveoli 
for  themselves ;  this  they  generally  do  by  emerging  posterior  to  the 
deciduous  ;  but,  as  can  readily  be  imagined,  odontocele  or  encyst- 
ment  is  not  unfrequently  a  result. 

Note. — Sometimes,  long  after  the  period  at  which  the  second 
dentition  is  usually  completed,  the  incisors,  as  would  seem  to  be 
natural,  may  be  remarked,  each  occupying  its  respective  alveolus. 
Yet  here  we  may  have  odontocele.  One  of  the  incisors  that  we  see 
is  a  milk  tooth.  This  anomaly  could,  however,  deceive  only  the 
very  superficial  observer,  the  difference  in  the  classes  of  teeth  being 
sufficiently  marked. 

Because  of  this  non-absorption  of  deciduous  fangs,  arrest  in  the 
development  of  the  permanent  sometimes  occurs.  It  is  really  quite 
a  nice  point  in  practice  to  give  advice  in  such  cases ;  if  you  direct 
the  extraction,  aud  no  tooth  comes  to  replace  the  one  lost,  you  will 
be  sure  to  get  a  good  deal  more  censure  than  you  could  possibly 
deem  yourself  deserving. 

There  are  a  number  of  conditions  to  take  into  the  consideration 
of  such  a  case,  the  most  prominent  of  which  is  the  existence  or  non- 
existence of  the  anomaly  in  a  hereditary  point  of  view.  I  am 
acquainted  with  a  family  where  continued  integrity  on  the  part  of 
certain  front  deciduous  teeth,  conjoined  with  the  non-appearance  of 
the  permanent,  has  been  a  striking  peculiarity  as  far  back  as  the 
ancestors  can  be  remembered.  Ability  to  advise,  in  such  cases,  can 
only  be  gained  by  a  careful  study  of  the  laws  of  dentition  and  idio- 
syncrasies. 

Surgical  Relations. — In  an  examination  of  any  obscure  tumor  of 
the  maxillary  bones,  examine  the  dental  arch  ;  if  a  deciduous  tooth 
occupy  the  place  of  a  permanent,  the  existence  of  odontocele  may  be 
reasonably  inferred. 

Anomaly  Fourth. — Supernumerary  Teeth. — These  teeth  differ 
from  all  others  in  being  doubly  fully  conoidal ;  this  is  the  rule.  It 
is,  however,  to  be  remembered  that  we  meet  with  exceptions.  Har- 
ris mentions  having  seen  them  so  resembling  the  natural  teeth  as 
"to  make  it  impossible  to  distinguish  which  should  be  called  the 
supernumerary;"  as  for  myself,  I  have  never  met  with  such  decided 
exceptions. 

An  encysted  condition  of  these  bodies  obscures  very  much  the 

10 


146  ORAL  DISEASES  AND  SURGERY. 

recognition  of  their  existence.  In  diagnosing  diseases  of  the  mouth, 
we  must  bear  in  mind  that  we  have  such  odontoceles.  The  study 
of  the  evolution  of  such  teeth  is  very  interesting,  but,  of  course,  con- 
cerns the  physiological  rather  than  the  surgical  author.  We  may 
remark,  however,  that  they  do  not  seem  to  be  necessarily  a  dermatic 
production,  and  the  appearance  of  them  in  the  mouth  is  as  unac- 
countable as  their  association  with  ovarian  and  other  remote  tumors. 
Surgical  Relations. — With  the  exception  of  the  relation  of  super- 
numerary teeth  to  tumors,  we  have  only  to  deal  with  them  as  they 
so  strangely  present  themselves  in  the  mouth.  Let  me  give  an 
example  of  such  practice.  A  patient  presents  himself  and  tells  you 
that  there  is  a  piece  of  bone  working  out  through  his  mouth;  and, 
truly,  an  examination  will  seem  to  verify  his  assertion.  But  there  is 
one  point  which,  if  observed,  will  never  mislead.  Necrosis  is  always 
preceded  by,  and  is  associated  with,  tumidity  of  the  gum.  The 
eruption  of  a  supernumerary  tooth  is  very  gradual,  and,  so  far  as  my 
experience  goes,  is  never  associated  with  inflammation.  To  extract 
such  teeth,  wait  until  they  have  emerged  to  the  base  of  the  cone; 
or,  if  such  waiting  does  not  seem  desirable,  carefully  force  sharp- 
pointed  forceps  through  the  bone  until  you  may  be  able  to  grasp  this 
base,  then  with  a  rotary  motion  you  may  easily  pull  them  away. 
Their  alveoli  need  no  attention. 

Anomaly  Fifth. —  Third  Dentitions. — I  would  not  be  understood 
as  referring  here  to  that  extra  development  sometimes  occurring  in 
young  adult  life,  and  yet  the  mention  of  the  existence  of  such  an 
anonmly  is,  perhaps,  desirable.  Thus,  Columbus  reports  that  one  of 
his  children  had  three  sets  of  teeth.  Valerius  Maximus  and  Pliny 
relate  similar  facts.  A  son  of  Mithridates  is  said  to  have  had  two, 
and  Hercules  three.  I  myself  have  seldom  seen  this  anomaly,  and 
incline  to  think  that  its  existence,  in  these  modern  times,  is  not  co- 
extensive with  the  ancient  period.  I  have  certainly  had  quite  five 
hundred  persons  tell  me  that  such  and  such  tooth  or  teeth  were  the 
third  of  the  class,  but  examination,  in  almost  every  individual  case, 
has  satisfied  me  they  were  mistaken  ;  this  anomaly  has,  however, 
surgically,  little  or  no  signification. 

Third  dentitions,  as  here  referred  to,  are  those  which  are  asso- 
ciated with  advanced  age.  The  student  will  recognize  their  phys- 
iology when  I  classify  them  with  second  sight,  etc.  The  lesions 
of  this  anomaly  are  what  might  be  termed  associative — that  is, 
we  are  occasionally  so  deceived  by  them  as  to  be  led  falsely  to  in- 
terpret engorgements,  congestions,  etc. 


AN03fALIES  OF  SECOND   DENTITION.  147 

A  single  case  will  illustrate  the  anomaly.  An  individual,  aged 
sixty-five,  applied  to  Dr.  Chapin  Harris,  suffering  with  pain  in  the 
gums  and  jaws.  No  local  lesion  was  at  all  discoverable.  A  tenta- 
tive treatment  was  resorted  to.  The  apparent  disease  went  on, 
however,  entirely  uninfluenced  by  the  experimental  medication,  until 
at  last  it  attained  an  intensity  positively  excruciating.  In  twenty- 
one  days  the  mystery  was  explained  by  the  eruption  of  a  third  set 
of  teeth.  The  report  of  another  case  is,  at  the  time  of  this  writing, 
appearing  on  the  pages  of  various  journals  describing  a  new  and  full 
dentition  in  the  person  of  a  gentleman  eighty  years  of  age. 

Anomaly  Sixth. — Association  of  the  odonto-])erioHteum  ivith  the 
membrane  of  the  antrum  of  Highniore. 

It  will  be  remembered  that  the  easiest  entrance  to  the  maxillary 
sinus  is  through  the  palatine  fang  either  of  the  second  or  the  first 
molar  tooth.  It  is,  indeed,  as  I  well  know  from  experience,  a  very 
common  thing  to  find  the  roots  of  these  teeth  perforating  the  cavity. 
Remembering  this  association  of  parts,  it  will  be  seen  that  many 
conditions,  which  may  have  been  deemed  obscure,  are  thus  made 
very  plain.  Dr.  Harris,  who  seemed  a  close  observer  in  disea.ses  of 
the  mouth,  went  so  far  as  to  say  that  two  cases,  mentioned  by  Bell 
and  Bordenave,  were  the  only  authenticated  exceptions  where  ab- 
scess had  formed  in  this  cavity  at  any  other  point  than  that  at  which 
it  had  been  penetrated  by  the  root  of  a  tooth. 

A  case  mentioned  in  Braithwaite,  from  the  practice  of  a  Mr.  Louis 
Oxley,  of  London,  illustrates  most  happily  the  relations  of  this 
lesion.  A  young  woman,  of  rather  strumous  habit,  complained  of 
a  dull,  aching  pain  under  the  orbit.  The  pain  lasted  from  three  to 
four  months,  attended  by  a  gradual  elevation  of  the  orbital  surface 
of  the  maxilla.  The  eye  above  this  surface  became  at  length  so 
affected  as  entirely  to  lose  its  functions.  At  this  stage  of  the 
case  she  was  directed  to  use  leeches  and  blisters  behind  the  ears, 
and  to  employ  drastic  purges.  After  three  months'  blindness,  the 
patient  first  perceived  a  discharge,  from  the  right  nasal  fossa,  of  a 
thick,  purulent  fluid.  This  discharge  had  existed,  he  says,  eighteen 
months,  when  he  first  saw  the  case.  An  examination  of  the  mouth 
at  once  revealed  the  cause  of  so  much  misery,  and  the  removal  of 
three  roots,  in  a  state  of  periodontitis,  was  the  simple  means  by 
which  two  most  important  organs  regained  their  proper  functions. 

The  nasal  opening  of  the  maxillary  sinus,  it  is  known,  is,  in  a 
healthy  condition,  almost  closed  by  the  duplicature  of  membrane 
lining  the  turbinated    and   neighboring   bones;   congestion  of  this 


148  ORAL  DISEASES  AND  SURGERY. 

membrane  not  unfrequently  closes  it  entirely.  Thus  secretions  ac- 
cumulate, giving  alarming  and  threatening  disfigurements  to  the 
face.  The  weakest  points  in  the  osseous  boundaries  of  this  cavity 
are,  the  floor  of  the  orbit,  the  hard  palate,  the  tuberosity  of  the 
bone,  and  the  canine  fossa.  Any  accumulation  would  necessarily 
be  most  apt  to  vent  itself  at  one  of  these  four  points,  unless  atresia 
of  the  duplicated  membrane  alluded  to  should  occur,  and  which  is 
not  commonly  the  case. 

Note. — My  own  experience  regarding  acute  abscess  of  the  antrum 
is,  that  in  the  great  majority  of  cases  the  pus  seeks  to  vent  itself 
through  the  floor  of  the  cavity.  After  the  inflammatory  action  has 
passed  to  the  suppurative  stage,  you  will  notice  a  swelling  in  the 
roof  of  the  mouth  at  the  side  of  the  mesial  line,  corresponding  to  the 
diseased  cavity:  this  is  the  abscess  pointing,  and,  if  left  to  itself, 
will  be  sure  to  make  an  ugly  opening.  Such  a  result  will  be  found 
particularly  undesirable  if  there  should  be  any  specific  virus  linger- 
ing in  the  system.  But  wherever  this  abscess  should  tend  to  point, 
it  is  of  course  desirable  to  abort  it. 

If  the  assertion  of  Harris  is  true,  concerning  the  almost  invariable 
dental  origin  of  this  abscess  (and  certainly  my  own  experience, 
so  far  as  it  goes,  confirms  him;  for,  while  I  have  seen  many  cases 
of  this  kind,  I  have  yet  to  meet  with  one  where  the  treatment  indi- 
cated was  not  primarily  of  a  dento-surgical  character),  we  turn 
naturally  to  the  alveolar  arch,  seeking  there  the  source  of  offense 
and  defense.  For  a  single  moment,  then,  let  me  direct  attention  to 
a  few  dental  lesions  of  the  most  practical  character,  and  without  the 
ability  to  recognize  which,  the  practitioner  will  assuredly  find  him- 
self at  sea. 

Because,  when  you  turn  to  this  dental  arch,  you  find  it  entirely 
clear  of  teeth,  and  healthy-looking,  you  are  not  hastily  to  conclude 
that  the  primary  lesion  is  not  in  such  direction.  You  are  to  re- 
member that  fangs  of  teeth  are  not  unfrequently  broken  oft'  in  an 
attempted  extraction,  and  that  when  so  broken,  particularly  if  very 
deep  in  the  socket,  the  practitioner  is  not  unapt  to  leave  such  pieces 
alone.  Now,  it  is  easy  to  understand  that  a  fang  so  situated  maybe 
the  source  of  extensive  disease,  and  yet  the  gum  over  it  be  without 
break  in  its  continuity,  and  perfectly  healthy-looking.  The  relation, 
in  such  a  case,  of  the  fang,  is  with  the  antrum, — it  need  necessarily 
have  no  external  sinus.  Make  here  an  explorative  incision  along 
the  gum  down  to  the  bone.  If,  happily,  you  come  to  a  cavity,'you 
will  have  hit  on  the  origin  of  the  trouble ;  but  if  you  find  nothing, 


ANOMALIES   OF  SECOND   DENTITION.  149 

you  have  made  only  a  simple  incised  wound,  which  left  to  itself  will 
heal  in  a  few  hours. 

Again,  because  the  part  may  have  its  usual  complement  of  teeth, 
and  each  tooth  should  seem  to  be  perfectly  healthy,  you  are  not  to 
turn  hastily  ayay.  There  may  be  in  one  of  these  teeth  a  dead  pulp. 
To  satisfy  yourself  on  this  point,  take  up  a  delicate  steel  instrument, 
and  strike  with  it  each  tooth  separately,  directing  your  patient  to 
note  any  difference  in  the  sensations;  if  he  should  start  when  you 
strike  a  particular  tooth,  my  veracity  for  it,  you  have  found  the 
primary  lesion.  But  still  again,  the  lesion  may  be  here,  and  yet 
the  patient  not  express  the  anticipated  pain.  Take  now  a  hand- 
mirror,  and,  placing  your  patient  full  in  the  sunlight,  reflect  the  rays 
over  tlie  teeth,  by  placing  the  glass  back  of  them.  If  in  the  arch  is 
a  dead  tooth,  you  will  remark  an  opacity  in  it  not  belonging  to  its 
neighbors  :  this  is  the  offense  ;  extract  it. 

If  a  tooth  has  a  plug  of  metal  in  it,  take  the  filling  out:  the 
cavity  will,  not  unlikely,  be  found  to  communicate  with  the  pulp 
chamber. 

If,  now,  we  study  periodontitis,  the  student  will  be  prepared  to 
make  the  most  of  the  cases  which  we  shall  have  to  consider  under 
various  heads  associated  with  such  lesions. 

Periodontitis. — Periodontitis,  peridentitis,  pericementitis,  dental 
periostitis,  as  the  condition  is  variously  designated,  implies  inflam- 
mation of  the  membrane  associating  the  root  of  a  tooth  with  its 
alveolus. 

Periodontitis,  like  inflammation  in  general,  may  exist  either  in 
the  condition  of  activity  or  chronicity. 

The  active  form  of  the  condition  is  most  frequently  found  as  the 
expression  of  direct  local  irritation  ;  the  chronic,  as  the  result  of 
systemic  influences. 

Acute  or  active  periodontitis,  if  not  resolved  or  aborted,  has  a 
history  which  associates  it  with  parulis.  It  commences  commonly 
with  a  dull,  heavy,  gnawing  pain  in  the  parts  affected  :  this  is  the 
signification  of  simple  vascular  excitement.  As  the  grade  of  the 
inflammation  advances,  pain  increases  with  it.  The  tooth  seems  to 
the  touch  of  the  patient  to  project  beyond  its  fellows,  and  really  does 
so.  Occlusion  of  the  jaws  gives  pain,  which  pain  so  grows  in  severity 
that  the  whole  attention  of  the  patient  becomes  directed  to  the 
avoidance  of  the  contact.  Finally,  when  not  arrested,  the  action 
goes  on  to  the  suppurative  condition, — the  state  of  abscess;  and 


150  ORAL   DISEASES  AND  SURGERY. 

this  pus,  discharging  through  a  sinus  which  it  creates  for  the  con- 
venience,— generally  opening  upon  the  gums  opposite  the  diseased 
point, — establishes  the  condition  of  parulis. 

Chronic  periodontitis — subacute,  as  it  might  with  as  much  pro- 
priety be  termed — has  a  history  markedly  distinguishing  it  from  the 
sthenic  form  :  its  causes  are  manifold.  Mercurial  ulitis  is  perhaps 
among  the  most  frequent  of  .the  causes.  Scorbutus  is  another  very 
common  cause,  being  abundantly  expressed  in  every  neighborhood 
where  much  pork  is  eaten  to  the  exclusion  of  a  mixed  diet.  From 
the  exanthems  many  cases  have  origin  :  of  such  causes  scarlatina 
seems  the  most  provocative  ;  rubeola  follows  this  in  frequency.  The 
phosphoric  impression,  as  seen  in  connection  with  the  workmen  in 
match-factories,  is  a  cause  familiar  to  every  surgeon.  Neul'algic 
reflections  certainly  beget  irritability  in  the  peridental  tissue,  and 
which,  in  cacoplastic  states  of  the  blood,  may  degenerate  the  nutri- 
tional changes.  Rheumatism  and  gout,  as  toxical  conditions,  are  fre- 
quently found  from  clinical  experimentation  to  be  the  irritants  support- 
ing a  resisting  periodontitis.  Uterine  reflections,  particularly  from 
the  menstrual  relation,  are  other  causes.  Age  is  a  common  cause, — 
old  people  losing  their  teeth  by  a  degenerative  condition  of  this 
membrane,  which  allows  the  organs  to  loosen  and  drop  out;  or  the 
same  result  is  found  frequently  to  coincide  with  tubular  consolidation 
of  the  fangs,  the  excess  of  nutritional  work  thrown  thus  upon  the 
periodonteuni  exhausting  finally  the  excitability  of  this  membrane. 
Accumulation  of  tartar,  as  it  is  called,  is  a  common  and  frequent 
cause  of  chronic  periodontitis. 

Chronic  periodontitis — existing  as  a  primary  form — difi"ers  diag- 
nostically  from  the  acute  condition  in  the  absence  of  the  sthenic 
expressions.  The  tooth  or  teeth  affected  grow  sore,  tender,  and 
elongated,  but  the  progress  is  so  slow  as  not  to  make  the  oflFense  of 
sufficient  import  to  the  comfort  of  the  patient  to  invite  any  vigorous 
antagonism,  the  expression  commonly  being  that  associated  with 
the  chronicity  so  frequently  succeeding  the  acute  form  ;  the  parts 
are  recognized  to  be  in  the  state  of  disease,  but  the  condition  is  suf- 
ficiently bearable  to  be  endured. 

The  acute  and  chronic  forms  of  periodontitis  find  constantly  a 
combined  relation.  Thus,  the  constitutional  ofi"enses  are  found 
capable  of  provoking  the  active  condition,  while  local  offenses,  as 
instanced  in  salivary  calculus,  conjoin  not  unfrequently  with  the 
chronic  state. 

Chronic  periodontitis,  except  as  associated  with  the  acute  form,  is 


ANOMALIES  OF  SECOND   DENTITION.  151 

not  found  to  tend  to  parulis,  but  when  degenerating  to  the  forma- 
tion of  pus,  has  the  discharge  about  the  neck  of  the  diseased  tooth 
or  teeth. 

The  importance  and  frequency  of  periodontitis  rendering  the  con- 
dition one  most  necessary  to  be  thorough!}^  understood,  advantage 
may  be  taken  of  the  present  and  succeeding  chapters  to  direct  atten- 
tion to  the  subject  in  the  required  detail. 

First  and  most  commonly,  it  will  be  seen  that  the  acute  form  of 
the  condition  we  study  depends  on  preliminary  disease  in  the  dental 
pulp,  this  organ  being  in  a  state  of  profound  inflammation,  affecting 
the  periodonteum  by  its  continuity  of  relatioi>ship,  or  otherwise 
being  dead,  and  proving  the  source  of  offense  by  its  post-mortem 
changes  and  influences.  In  any  and  every  case  of  acute  periodon- 
titis which  presents  itself,  whether  exhibiting  the  very  first  expres- 
sion of  a  scarcely  noticeable  uneasiness,  or  the  tooth  being  so 
elongated  and  tender  as  to  render  the  slightest  touch  unbearable, 
attention  is  to  be  directed  to  the  condition  of  the  pulp  cavity.  If 
this,  as  is  frequently  the  case,  is  found  exposed,  and  the  pulp  dead 
or  absent,  then  it  is  at  once — no  evidence  of  other  vice,  either  consti- 
tutional or  local,  being  seen — to  be  inferred  that  the  trouble  is  that 
of  an  open,  free  inflammation,  demanding  for  its  relief  common 
antiphlogistic  medication. 

Where  a  pulp  cavity  is  found  closed,  the  tooth  being  undecayed, 
or  otherwise  having  in  it  a  tilling,  a  first  indication  directs  an  open- 
ing into  the  pulp  chamber,  no  hesitation  being  necessary,  as  in  per- 
haps all  instances  in  which  a  tooth  has  become  thus  tender  to  the 
touch,  the  pulp,  if  not  found  actually  dead,  will  be  in  such  a  state  of 
congestion  that  its  destruction  has  been  insured.  If,  however,  it 
is  desired  to  attempt  the  abortion  both  of  pulpitis  and  periodontitis, 
the  plan  suggested  of  uncovering  the  organ  will  be  the  wisest  which 
may  be  pursued,  as  thus  depletion  could  be  practiced  with  the  most 
immediate  effect,  and  medication  find  direct  application.  Instances, 
however,  present — and  these  are  much  the  most  numerous — where 
the  periodontitis  depends  on  a  preliminary  operation  in  which  the 
pulp  of  a  tooth  has  been  purposely  destroyed  and  removed,  its  place 
being  occupied  by  metal  as  in  what  we  are  to  study  as  a  root-filling. 
Here  it  is  not  unlikely  the  trouble  depends  simply  on  the  excess  of 
work  thrown  upon  the  periodonteum  from  the  abstraction  of  the  pulp 
life  ;  or  it  may  be  that  the  tooth  is  unable  to  endure  the  thermal 
changes  resulting  from  the  presence  of  the  filling  material ;  or  per- 
haps some  particle  of  the   pulp  was  not  removed,  which,  disinte- 


152  ORAL   DISEASES  AND  SURGERY. 

grating  and  decomposing  into  its  gaseous  elements,  has  provoked  the 
inflammation  through  pressure  upon  the  parts  about  the  foramen  ;  or, 
still  again,  it  may  be  that  a  slight  twist  of  the  cotton  or  gold,  or 
whatever  may  have  been  used  to  fill  the  root,  has  been  forced 
through  the  foramen.  The  consideration  of  a  condition  of  this  nature 
calls  always  for  the  exercise  of  individual  judgment  aside  from  ordi- 
nary rules.  If  a  pulp  cavity  has  been  well  and  scientifically  treated, 
it  would  scarcely  seem  necessary  or  desirable  to  undo  what  had  been 
done  ;  as  having  been  properly  done,  with  all  collaterals  considered, 
it  is  not  to  be  esteemed  that  undoing  and  doing  over  could  improve 
mattei's.  We  would  therefore  naturally  consider  the  periodontitis 
as  the  lesion,  and  consider  this  alone.  If,  on  the  contrary,  there  is 
doubt  of  the  operation, — if  there  is  reason  to  infer  that  any  portion 
of  the  pnlp  remains  in  the  cavity,  or  that  a  twist  of  the  filling  has 
passed  the  foramen, — then  a  first  indication  lies  in  such  direction. 

Accumulation  of  tartar  provoking  periodontitis  would  not  be  diffi- 
cult to  distinguish,  and  the  indication  for  its  removal  would  be  self- 
suggesting. 

False  occlusion,  another  cause  of  periodontitis,  calls  alone  for  its 
appreciation  to  an  observation  which  considers  the  common  articu- 
lation. A  tooth  which,  from  any  cause,  strikes  prematurely,  is  certain 
to  succumb  to  the  irritation  if  the  offense  be  continued  for  any  length 
of  time.  In  such  relation,  the  condition  of  newly-placed  fillings  is  to 
be  considered.  A  plug  is  never  to  afford  the  feeling  of  special  contact. 
When  a  filled  tooth  becomes  sensitive  in  its  periodonteum,  a  very  first 
attention  is  wisely  directed  to  the  contact ;  should  the  metal  be  unduly 
prominent,  it  will,  most  likely,  be  at  once  noticed  by  an  indentation 
seen  upon  its  surface.  Should  this,  however,  not  exist,  the  surface 
may  be  rubbed  over  with  a  little  pulverized  pumice-stone,  so  as  to 
remove  the  general  polish :  the  contact  of  the  opposing  tooth,  if  now 
it  unduly  touch,  will  distinguish  itself  by  the  polish  it  affords. 

Teeth  unduly  occluding  from  false  articulation  are  to  find  remedy 
in  the  file,  which  is  to  cut  away  from  the  unaffected  organs  (or,  if 
seemingly  necessary,  from  the  one  which  has  expressed  the  irritation) 
such  portion  as  shall  remedy  the  defect. 

Still  another  cause  of  periodonteal  inflammation,  not  unfrequently 
met  with,  results  from  accidents  in  the  use  of  escharotics,  which, 
having  been  applied  to  a  cavity  for  the  destruction  of  the  dental 
pulp,  have  escaped  and  fallen  around  the  neck  of  the  tooth.  A 
similar  result  has  ensued  from  application  of  caustics  to  the  gum  for 
the  arrestation  of  mucous  oozing,  or  hemorrhage.     Still  again  has 


ANOMALIES   OF  SECOND   DENTITION.  153 

such  inflammation  been  provoked  by  ligatures  used  with  the  rubber 
dam,  or  by  forgotten  rings  of  rubber  tubing  or  thread.  In  Fig.  53 
is  exhibited  such  a  ringed  tooth,  where  the  cause  of  a  defying  abscess 
was  only  discovered  after  extraction.  The  relation  of  ring  and  tooth 
is  just  as  when  removed  from  the  mouth. 

Still  another  cause  of  periodontitis,  but  one  happily  apt  to  tend 
to  rapid  self-cure,  is  found  in  the  process  of  wedging.  -piQ  53 
All  teeth  are  made  more  or  less  sore  through  such  mani- 
pulation, and  the  soreness  expresses  inflammation.  Such 
wedging,  however,  employed  in  the  mouths  of  old  persons, 
or  with  those  of  bad  constitution,  may  well  result  in  the 
necessity  for  a  medication,  aside  from  the  removal  of  the 
cause  exciting  the  trouble. 

Taking  it  for  granted  that  any  and  all  existing  sources  of  irrita- 
tion have  been  removed,  an  acute  periodonteal  inflammation,  taken 
in  time,  may  in  nine  out  of  twelve  cases  be  aborted  as  follows.  Pass 
a  lancet  several  times  through  the  gum  down  to  the  alveolus;  let 
the  patient  hold  water  in  the  mouth,  so  as  to  prevent  the  formation 
of  clot,  and  provoke  free  bleeding.  As  soon  as  the  vessels  and 
capillaries  have  disgorged  themselves,  paint  the  parts  heavily  with 
tincture  of  iodine,  to  which  has  been  added  one-fourth  part  of  tincture- 
of  aconite,  both  being  of  the  ofBcinal  strength.  The  philosophy  of 
this  treatment  is  sufficiently  evident  not  to  need  explanation. 

A  routine  plan  followed  commonly  with  satisfactory  results  in 
incipient  periodontitis  is  as  follows  : 

Place  the  feet  of  the  patient  in  very  hot  water.  Apply  just  in  front 
of  the  ear  a  fly-blister  of  the  size  of  a  silver  dime  piece,  and  upon 
the  nape  of  the  neck  a  second,  the  size  of  a  silver  dollar.  Admin- 
ister internally  twenty-five  grains  of  the  bromide  of  potassium, 
having  combined  with  it  five  drops  of  the  tincture  of  veratrum  viride, 
— this  combination  to  be  repeated  in  four  hours,  if  relief  be  not 
sooner  obtained.  Lance  the  gums  freely  with  a  very  sharp  lancet, 
and  afterwards  keep  cotton  applied,  saturated  with  the  fluid  extract 
of  Hamamelis  Virginicus ;  of  which  the  best  is  the  preparation  known 
as  Pond's,  or  this  combined  with  equal  parts  of  the  phenol  sodique. 
This  treatment,  if  all  local  cause  of  offense  has  been  removed,  will 
seldom  fail.  It  is  found  well  to  retain  the  feet  in  the  hot  water  until 
the  patient  grows  faint  or  breaks  out  into  a  perspiration.  In  the 
plethoric,  in  addition  to  the  above  course,  half  an  ounce  of  the  sul- 
phate of  magnesia  may  be  given  in  a  goblet  half  filled  with  water. 

In  the  employment  of  the  arterial  sedatives  in  periodontitis,  as  in 


154  ORAL  DISEASES  AND   SURGERY. 

an  inflammation  of  any  other  part,  regard  is  always  to  be  had  to  the 
condition  of  the  pulse,  such  medicaments  being  alone  indicated  in 
the  sthenic  conditions,  and  acting-  here  with  an  efficiency  and  influence 
sometimes  quite  magical.  Of  such  sedatives  few  seem  possessed  of 
the  virtue  of  veratrum  viride.  I  am  well  satisfied  that  it  is  in  very 
many  cases  all  that  is  needed  in  the  treatment.  Hydrate  of  chloral 
is  another  of  this  class  of  agents  highly  commending  itself.  That  it, 
however,  possesses  sedative  qualities  dangerous  in  extent  is  scarcely 
to  be  doubted.  To  commence  its  exhibition  in  doses  of  not  over  ten 
grains  is  to  err  on  the  safe  side.  It  is,  however,  on  the  bromide  of 
potassium  that  every  dependence  is  to  be  placed  :  it  maj'  be  given  in 
doses  varying  from  ten  grains  to  one  drachm,  or  even  one  hundred 
grains,  twenty  grains  being  the  ordinary  dose ;  this  is  to  be  pre- 
scribed in  water,  and  may  be  repeated  each  two,  four,  or  six  hours, 
as  seems  indicated. 

As  adjuncts,  leeches  are  occasionally  to  be  employed  with  great 
benefit.  If  the  inflammation  is  associated  with  the  lower  maxilla, 
they  may  be  applied  below  the  jaw  ;  or,  if  objection  be  not  made  by 
the  patient,  they  may  be  used  as  in  the  ui)per  jaw,  being  applied 
directly  to  the  gum. 

A  very  simple  plan  of  treating  incipient  periodontitis,  and  which 
will  frequently  be  followed  by  immediate  relief,  consists  in  making 
a  minute  blister  upon  the  gum  overlying  the  affected  root,  through 
an  application  of  a  saturated  solution  of  iodine. 

Lead-water  and  laudanum,  as  used  so  commonly  in  general  surgical 
practice,  is  found  a  valuable  refrigerant  lotion  to  the  inflamed  parts, 
being  applied  on  a  pledget  of  cotton  placed  between  the  gum  and 
cheek.     A  satisfactory  combination  will  be  found  as  follows: 

R. — Plumbi  acetatis,  5j  ; 
Tincturee  opii,  sss; 
Aquae,  §x.     M. 

To  protect  the  inflamed  tooth  from  contact  with  its  neighbors, 
resort  is  to  be  had  to  a  cap  placed  over  adjoining  organs.  To  this 
end,  gutta  percha  is  commonly  employed,  being  easy  and  instantane- 
ous of  application,  requiring  alone  that  a  piece  of  the  material  about 
an  inch  square  be  softened  in  a  flame  and  moulded  over  the  parts,  a 
mouthful  of  cold  water  hardening  it  into  the  required  resistance. 
An  instrument,  however,  more  delicate,  is  found  in  a  cap  of  silver, 
as  devised  by  Dr.  J.  H.  McQuillen.  (See  Fig.  54.)  Such  a  cap  is 
quickly  made  by  the   mechanical   dentist,   he  requiring  alone  an 


ANOMALIES   OF  SECOND   DENTITION.  155 

impression  of  the  tooth  or  teeth  proposed  to  be  capped,  and  which  is 
secured  in  a  moment  by  pressing  over  and  around  them  a  small  lump 
of  softened  beeswax. 

Ad  acute  periodontitis  resisting  the  various  means  here  suggested, 
the  attack  increasing  in  severity,  the  surgeon  finds  himself  compelled 
to  abandon    antiphlogistics,  the  indication    being 
to  advance  the  condition  to  the  suppurative  point  Fig.  54. 

as  quickly  as  possible.     To  this  end,  heating  and 
exciting  medicaments  are  required;  warm  water  is 
to  be  held  in  the  mouth,  or  a  weak  dilution  of  the 
tincture    of    capsicum   may  be  employed ;    about 
twenty-five  drops  to  an    ordinary-sized  goblet  of 
warm  water  will  be  found  sufficiently  stimulating. 
Tlie  domestic  application  of  a  roasted  split  fig  to  the  gum  increases 
the  heat  of  the  parts  and  invites  suppuration  to  the  surface  to  which 
it  is  used.     Pursuing  a  natural  course,  the  attack  ends  in  the  forma- 
tion of  pus  and  the  establishment,  commonly,  of  open  parulis. 

The  appreciation  and  treatment  of  chronic  abscess,  whether 
founded  on  the  acute  form  or  arising  as  a  primary  condition,  are  to 
be  found  in  a  recognition  of  the  indi(;ations  of  the  associated  condi- 
tions. These  the  reader  will  find  considered  with  all  fullness  and 
clinical  care  in  the  chapters  on  "Alveolar  Abscess,"  "Diseases  of 
the  Gums,"  "Necrosis,"  and  "  Odontalgia,"  to  which  he  is  referred. 

Anomaly  Seventh. — Germs  of  Heterogeneous  Development. — It 
occasionally  happens  that  the  dental  germ,  instead  of  arranging  its 
parts  according  to  the  ordinary  laws  of  its  nature,  assumes  the 
most  fantastic  and  heterogeneous  shapes,  giving  such  a  variety  of 
appearances  that  only  a  close  attention  may  appreciate  its  dental 
character.  Tumors  of  complex  kinds  are  thus  occasionally  pro- 
duced, and,  unless  appreciated,  are  necessarily  the  source  of  much 
anxiety  both  to  surgeon  and  patient.  In  an  admirable  memoir  by 
M.  Forget,  crowned  at  the  Academy  of  Sciences,  Paris,  in  1859,  are 
illustrations  of  cases  both  of  this  seventh  and  the  ordinary  anomalies. 
I  present  them  to  my  readers  as  being  studies  than  which  it  would 
be  time  wasted  to  search  for  better. 


1,56  ORAL  DISEASES  AND  SURGERY. 


PLATE   I. 

Fig.  1. — h.  Osseous  tumor  united  to  a  molar  tooth  (a). 
Fig.  2. — a,  b.  Section  of  the  tooth  and  of  the  tumor. 

Fig.  3. — a,  b.  Dental  tumor  formed  by  the  anomalous  development  of  the 
first  two  molars. 

a.  Summit  of  the  tumor,     b.  The  root  of  the  tumor. 

Fig.  4. — a.  Cyst  of  the  right  branch  of  the  inferior  maxillary  bone,  the 
cavity  of  which  is  made  visible  by  the  circumferential  resec- 
tion of  its  external  wall. 

b.  A  molar  tooth  inclosed  in  the  osseous  tissue,  and  en  relief  u'pon 

the  bottom  of  the  cyst. 

c.  External  wall  of  the  cyst,  inverted. 

d.  Condyle  and  neck  of  the  jaw. 

e.  Summit  of  the  coronoid  apophysis,  with  the  insertion  of  the  tem- 

poral muscle. 
Fig.  5. — Upper  jaw  of  a  horse  ;  view  of  half  of  the  palatine  face. 

a.  Osseous  cyst  developed  in  the  interior  and  right  side  of  the  jaw; 

it  includes  the  tumor  represented  by  Fig.  6. 

b.  Right  canine,  thrust  backward  and  inward  toward  the  medio- 

palatine  line. 

d.  Alveolus  of  the  left  canine  tooth. 

e.  Osseous  perforation,  conducting  to  the  interior  of  the  cyst. 
Fig.  6.  Intramaxillary  osseous  tumor  (natural  size) ;  it  was  contained  in 

the  cyst  represented  in  Fig.  5. 
Fig.  7  (300  diameters). — Represents  a  part  of  the  section  of  the  tumor  shown 
in  Fig.  6.  This  tumor  appears  to  be  formed  entirely  of  the 
cement  or  osseous  substance  surrounding  the  dental  root.  It 
is  an  exostosis  of  the  dental  cement.  This  exhibits  the  struc- 
ture described  in  the  explanation  of  Fig.  4,  Plate  I. 

a.  Vascular  canaliculi  of  the   osseous   substance  of  the   tumor 

(Havers'  glands).  The  tumor  is  traversed  by  these  as  in  the 
normal  osseous  substance, — only  they  are  more  rare,  more 
scattered,  and  more  irregularly  distributed. 

b.  Osteoplasts  disposed  circularly,  or  nearly  so,  in  a  concentric 

manner  around  the  Haversian  canal,  but  less  exact  and  evident 
than  in  the  normal  condition. 

c.  The  osseous  substance,  properly  so  called,  in  which  the  osteo- 

plasts, or  characteristic  cavities  of  the  osseous  tissue,  are 
excavated. 


IPIi-A-TE   I. 


m 


%2 


F,p 


(157) 


/^-* 


"*    '— ^ 


(158) 


ANOMALIES  OF  SECOND  DENTITION.  159 


PLATE    II. 

Fig.  1,  Represents  a  cyst  occupying  the  whole  extent  of  the  right  half  of 
the  body  of  the  lower  jaw,  and  of  the  coronoid  apophysis. 
The  external  wall  of  the  cyst  has  been  removed,  and  permits 
a  view  of  the  cavity,  bounded  by  the  internal  wall  b,  which 
remains. 

a.  The  wisdom  tooth,  developed  in  an  anomalous  fashion  in  the 
base  of  the  coronoid  apophysis. 

c.  Dental  canal,  open  through  the  whole  of  its  extent.  It  does  not 
communicate  with  the  cavity  situated  above  it. 

Fig.  2. — d.  Right  side  of  the  inferior  jaw,  affected  by  the  rarefying  osteite. 

a.  Large  molar  tooth  encysted  in  the  bone. 

b.  Interior  of  the  cyst,  with  a  black  bottom,  representing  the  mem- 

branous tissue  that  lined  its  surface. 

Fig.  3. — Same  cyst,  open  at  the  side  of  the  mouth.  It  reproduces  (a  and  b) 
the  aforesaid  anatomical  arrangements. 

Figs.  2  and  3. — c,  c.  Three  incisor  teeth,  the  canine  tooth  and  the  first  two 
molars,  removed  from  their  position,  and  retroverted  one  upon 
another. 


JPXjJ^TIE]    XX, 


(160) 


:px.-a.tei  XX. 


n 


(161) 


162  ORAL  DISEASES  AND   SURGERY. 


PLATE    III. 

ANOMALIES   IN   POSITION    OF    THE   TEETH. 

Fig.  1.— a.  Incisor  tooth  retroverted,  and  directed  toward  the  intramaxil- 
lary  symphysis. 

Fio.  2,—c.  Canine  tooth  developed  in  the  thick  part  of  the  floor  of  the  nasal 
fossa;,  where  it  forms  a  prominence  :  the  root  is  directed  for- 
ward. 

b,  b.  Section  of  the  maxillary  sinus. 

d.  Nasal  spine. 

a,  a.  Posterior  edge  of  the  nasal  fossag. 

Figs.  3  and  4. — Two  other  examples  of  anomalies  in  the  position  of  the 
teeth. 


I 


IPXiJ^TiE    III. 


(163 


I=Xj-A.TE    III, 


i\ 


1G4) 


ANOMALIES  OF  SECOND   DENTITION.  165 


PLATE    IV. 

Fig.  I. — a,  a.  Second  grindiog  tooth  of  a  horse,  natural  size,  with  considera- 
ble development  of  the  roots,  transformed  into  two  spheroidal 
swellings. 
b,  h.  Portions  of  the  maxillary  bone  sheathed  in  the  tumor,  and 
broken  in  its  extraction, 
c.  Orifice  conducting  to  the  interior  of  an  intradental  cavity. 
d,  d.  Circular  groove  corresponding  to  the  alveolar  arch,  and  form- 
ing a  sort  of  strangulation  between  the  tuberosity  a  and  the 
swelling  e,  which  is  underneath. 
/.  Inferior  surface  of  the  crown  of  the  tooth. 

Fig.  2. — Microscopic  examination  of  the  tumor  (300  diameters). — Eepresents 
part  of  a  thin  section  of  the  tumor  shown  in  Fig.  1.  The 
tumor  was  formed  jointly  by  a  hypertrophy  of  the  dental 
ivory  and  a  hypertrophy  or  exostosis  of  the  cement,  the  greatest 
part  being  formed  of  the  substance  of  the  cement. 

a,  h.  Represents  the  ivory  in  its  canaliculi — not  ramified  in  this 
section — and  terminating  near  the  union  of  the  ivory  and 
enamel, 
c,  d,  e.  Exhibits  the  mammillated  arrangement  seen  in  the  cement 
at  certain  points  of  the  surface  of  union  with  the  ivory  or 
dentine.  This  arrangement,  often  very  elegant  under  the 
microscope,  is  also  met  with  in  the  normal  teeth. 

g,  h.  Osteoplasts,  or  characteristic  cavities  of  the  cement.  They  are 
especially  remarkable  for  their  size  in  all  the  preparations 
taken  from  this  piece. 
/.  Proper  substance  of  the  cement,  or  bone,  in  which  the  char- 
acteristic cavities  are  excavated.  It  is  here,  as  always,  homo- 
geneous; little  transparent,  except  when  it  is  reduced  to  very 
thin  laminae. 


IPXi^^TE   IV. 


166) 


IPXjJLTS   "V". 


Efi 


\,    b 


Fi^.z 


(167) 


168  ORAL  DISEASES  AND  SURGERY. 


PLATE    V. 

Fig.  1. — Intramaxillary  bone  bearing  the  two  permanent  incisors  (a,  a) 
superposed,  and  exhibiting  an  anomalous  development.  The 
alveoli  of  the  same  infantile  teeth  are  partly  destroyed;  this  sec- 
tion formed  the  deposit. 

Fig.  2. — Tumor  of  the  ramus  of  the  inferior  maxillary  bone,  affected  with 
moUities  ossium.  At  the  surface  are  many  openings  of  encysted 
abscesses;  and  the  last  molar,  the  crown  of  which  extends  slightly 
beyond  the  alveolar  edges,  and  is  developed  in  the  thick  part  of 
the  base  of  the  coronoid  apophysis. 

Fig.  3. — Section  of  the  ramus,  showing  the  numerous  abscesses  that  exist 
throughout  its  whole  extent. 


:f>IjJ^te  'V. 


Co.. 


(  169  ) 


CHAPTER    VIII. 


THE   TEETH   AND   THEIR   DISEASES. 


ALVEOLAE  ABSCESS. 


Periodontitis,  or  inflammation  of  the  alveolo-dental  periosteum 
(considered  in  the  previous  chapter),  when  not  successfully  com- 
bated, has  as  its  termination  alveolo-dental  abscess.  To  this  con- 
dition, as  a  distinct  one,  attention  may  now  be  directed. 

Alveolar  or  dental  abscess  has  of  course  the  history  of  an  inflam- 
mation and  suppuration  anywhere  in  the  body,  having  nothing 
peculiar  to  its  history,  except  as  such  peculiarities  associate  with 
the  anatomical  characteristics  and  influences  of  the  parts  involved. 
It  is  a  condition  in  which  a  tooth,  diseased  to  the  suppurative  point 
in  its  enveloping  membrane  or  periodonteura,  is  discharging,  through 
some  convenient  orifice  of  exit,  pus  secreted  by  or  formed  in  such 
membrane. 

The  local  features  of  alveolar  abscess  may  be  described  in  a  very 
few  words.  At  the  apex  or  somewhere  about  the  root  of  the  affected 
tooth,  a  degenerative  thickening  of  the  mem- 
brane occurs, — the  old  pyogenic  membrtwie,  as 
it  was  termed.  This,  in  its  unhealthy  condition, 
becomes  shreddy  and  stringy,  failing  to  organize 
the  lymph  constantly  exuded  or  effused  by  it. 
The  degeneration  of  this  lymph  is  pus.  As 
such  membrane  grows  thicker  and  softer,  and 
such  pus  accumulates,  it  becomes  evident  that 
space  and  vent  are  made  necessities ;  thus  ab- 
sorption, through  the  pressure,  is  effected,  and 
the  matter,  sooner  or  later,  finds  egress,  giving 
generally  that  peculiar  fistule  in  the  gum,  known 
as  parulis  or  gum-boil ;  the  most  vulnerable  wall 
of  the  surrounding  osseous  parietes  yielding  first,  thus  giving  the 
(170) 


Fig.  55. 


Sac  of  abscess  as  com- 
monly met  with  in  dental 
parulis. 


,        THE   TEETH  AND    THEIR  DISEASES.  171 

direction  and  locating  the  fistule.  The  morbid  process  exhibited  in 
an  inflamed  root-membrane  consists  in  the  accompaniment  of  the 
hyper^emia  by  a  hyperplastic  state  of  the  tissue-cells,  these  cells 
increasing  not  only  in  number  but  also  in  size.  In  this  change  it 
is  that  we  find  the  explanation  of  the  shreddy  periodonteum  seen 
more  or  less  markedly  upon  all  abscessed  roots. 

A  recognizable  hyperemia  is  not,  however,  a  necessity  for  the 
excessive  proliferation  of  connective-tissue  cells ;  hence  it  is  that 
epulic  tumors  frequently  have  origin  in  such  hyperplasticity  of  the 
odonto-alveolar  periosteum  where  expressions  of  vascular  change 
have  never  been  observed. 

The  formation  and  confinement  of  pus  in  a  cavity  so  obstinately 
closed  as  the  alveolus  of  a  tooth  must  necessarily  inflict  the  severest 
suffering,  and  such  pain  is  so  constant  an  attendant  of  the  condition, 
and  is  of  such  almost  unbearable  character,  that  any  means  calcu- 
lated to  abort  or  limit  its  persistence  is  to  be  hailed  as  a  boon.  I 
take  it  for  granted,  judging  from  observation,  that  it  is  the  severest 
form  of  odontalgia.  The  condition  of  acute  pain,  however,  is  con- 
fined to  the  period  intervening  between  the  accession  of  the  acute 
inflammatory  attack  and  the  escape  of  the  pus;  the  period,  properly 
speaking,  of  periodontitis, — a  period  lasting  from  two  days  to  ten  : 
abscess  fully  formed,  pain  becomes  limited  to  soreness.  The  treat- 
ment of  the  perfected  alveolar  abscess  is  very  simple,  at  least  as 
the  indications  are  concerned  ;  consisting  in  the  breaking  up  of  the 
cyst  and  sac,  and  exciting  an  action  of  sufficiently  healthy  character 
to  fill  with  granulations,  of  organizable  force,  the  fistule. 

The  appreciation  of  the  cure  of  alveolar  abscess  begins  of  course 
with  the  treatment  of  the  acute  periodonteal  trouble,  of  which  it  is 
seen  to  be  simply  a  result.  This  was  considered  in  the  previous 
chapter,  leaving  here  little  to  add,  except  that  if  such  means  as 
were  recommended  fail  in  securing  resolution,  more  formidable,  if 
thought  desirable,  are  to  be  brought  into  requisition. 

As  periodontitis  is  so  frequently  aborted  by  scarifying  the  gums 
freely  and  deeply,  and,  after  the  congested  vessels  have  relieved 
themselves,  constringing  the  parts  by  applications  of  strong  tincture 
of  iodine,  so  parulis  can  very  frequently  be  anticipated  by  the  fol- 
lowing trifling  operation  : 

With  a  sharp  scalpel  make  a  slight  cut  through  the  soft  parts  at 
the  apex  of  the  affected  tooth  ;  next  take  up  a  spear-pointed  drill 
and  pierce  through  the  outer  plate  of  the  bone  into  the  cavity  in 
which  the  sac  is  being  developed,  break  up  this  sac,  and,  by  means 


172  ORAL  DISEASES  AND   SURGERY.  .% 

of  a  delicate  tent,  keep  the  wound  patulous  for  a  few  days.  This 
little  operation,  I  am  well  assured,  through  a  pleasant  experience, 
commonly  spares  the  patient  upon  whom  it  is  practiced  days  of  the 
excruciating  torture  which  belongs  to  the  formative  stage  of  this 
disease.  The  philosophy  of  it  will,  I  think,  be  at  once  recognized. 
Judgment  is  demanded,  however,  as  to  the  time  when  such  puncture 
is  to  be  made;  it  is  to  anticipate  the  moment  at  which  pressure 
from  accumulation  commences. 

I  cannot  here  help  excepting  to  the  common  practice  of  ordering 
warm  fomentations  to  the  face  in  incipient  abscess  ;  such  practice  is 
very  objectionable,  and  not  unfrequently  results  in  scars  which 
much  deform  the  patient.  If  the  practitioner  should  not  desire 
to  adopt  the  operative  suggestion  offered,  let  him  order  a  roasted 
fig  or  raisin  directly  to  the  affected  part ;  either  of  these  will  do 
equally  well  the  work  of  the  poultice.  Leeches,  general  blood-let- 
ting, vigorous  antiphlogistic  medication,  any  and  every  means  that 
promises  any  good,  should  come  between  the  periodontitis  and  the 
abscess. 

The  anomalies  of  alveolar  abscess,  if  such  a  term  might  be 
applied  to  conditions  not  at  all  infrequent,  may  perhaps  be  best 
studied  through  the  medium  of  examples.  I  select  a  few  from  my 
own  practice  and  that  of  others.  If,  happily,  they  may  serve  to 
throw  light  on  any  obscure  case  at  present  perplexing  some  young 
practitioner,  I  shall  feel  well  repaid  for  the  trouble  of  collecting 
them. 

A  few  years  ago  I  saw,  in  consultation  with  a  Dr.  B.  of  this  city, 

Mrs.  ,  who  had  been  afflicted  with  a  running  ulcer  at  the  apex 

of  the  chin  for  four  years.  During  this  period  the  lady  had  been 
under  the  care  of  some  five  or  six  different  practitioners,  and  had 
twice  been  operated  upon  for  supposed  disease  of  the  bone. 

Suggesting  that  the  origin  and  cause  of  this  fistule  might  be  found 
in  some  diseased  tooth,  I  was  assured  that  these  organs  had  been 
most  carefully  examined,  and  that  there  was  not  an  unhealthy  tooth 
in  the  mouth. 

A  superficial  examination  seemed  to  verify  the  truth  of  the 
assurance.  Not  satisfied,  however,  by  such  examination,  witli  a 
steel  instrument  I  commenced  striking  each  tooth  separately  ;  the 
patient  thought  that  in  the  left  inferior  lateral  incisor  she  experi- 
enced a  sensation  differing  from  that  of  the  others. 

Placing  her  now  in  the  full  sunlight,  I  reflected  the  rays  over 
the  teeth  by  means  of  a  hand-mirror;  this  test  satisfied  me  that 


THE    TEETH  AND    THEIR   DISEASES.  173 

the  incisor  alluded  to  had  lost  its  pulp, — it  showed  a  slight 
opacity. 

I  was  now  convinced  that  the  disease  was  alveolar  abscess,  and 
predicated  on  the  examination  that  an  opening  made  into  the 
aflfected  tooth  would  discover  the  death  of  its  pulp ;  this  was  done, 
and  the  tooth  found  dead,  as  anticipated.  The  offending  organ  was 
extracted,  some  necessary  local  attention  given  the  sinus,  and  the 
patient  was  well  in  a  week. 

Comment  on  this  case  scarcely  seems  necessary;  and  yet  it  may 
not  be  amiss  to  suggest  the  explanation  of  the  deceptively  healthy 
appearance  of  the  dead  tooth. 

When  the  pulp  of  a  tooth  dies,  discoloration  of  the  enamel  is  the 
common  result,  this  discoloration  being  caused  by  the  absorption  of 
the  dead  matter  by  the  tubuli  of  which  the  dentine  is  made  up. 
Occasionally,  however,  the  opacity  is  so  slight  as  to  be  scarcely 
perceptible,  and  this  depends  on  the  dense  character  of  the  tooth, — 
not  unfrequently  the  tubuli  being  so  occluded  as  to  destroy  their 
capillarity  :  the  dead  pulp  is  not  therefore  taken  up.  A  very  vas- 
cular tooth,  having  a  dead  pulp  in  its  cavity,  will  soon  be  turned 
almost  black.  A  tooth  in  which  the  death  of  the  pulp  has  been 
sudden  discolors  always  more  markedly  than  where  it  has  been  pre- 
ceded by  a  chronic  inflammation,  an  explanation  being  found  in  the 
absence  of  that  renewal  of  the  process  of  calcification  which  in  the 
chronic  condition  is  apt  to  occlude  the  tubuli. 

A  dead  tooth,  however,  can  always  be  distinguished  by  the  tests 
given. 

The  pathology  of  this  case  may  be  summed  up  very  briefly.  The 
death  of  the  pulp  provoked  periodonteal  difficulty.  The  inflammation, 
nncombated,  resulted  in  alveolar  abscess.  The  pus,  after  inducing 
by  its  presence  the  absorption  of  the  bone,  dissected  its  way  under 
the  soft  parts  down  to  the  apex  of  the  chin,  where  it  discharged 
itself, — the  abscess  passed  into  the  chronic  stage ;  the  annoying  and 
formidable  fistulous  ulcer  was  of  course,  because  of  its  character, 
rendered  incapable  of  being  healed  by  any  directly  local  treatment, 
or  that  not  addressed  to  the  true  seat  of  trouble. 

In  another  consultation  I  saw  a  Miss  B ,  a  young  lady,  nine- 
teen years  of  age.  In  this  patient,  a  fistule  in  the  very  centre  of 
her  hard  palate  had  existed  for  some  two  years,  giving  rise  to  great 
uneasiness  (as  it  had  refused  to  yield  to  much  treatment),  a  cancer- 
ous cachexia  existing  in  the  family.  The  denture  in  this  mouth 
was  also  so  complete  as  not  to  have  attracted  observation,  every 


174  ORAL  DISEASES  AND   SURGERY. 

tooth  being  perfect,  with  the  exception  of  a  single  molar,  which 
tooth  had  a  small  filling  of  gold  on  its  grinding  face.  The  filling  in 
this  tooth  was  removed,  and  the  pulp  found  dead.  Extraction  was 
resorted  to,  and  in  three  or  four  days  all  discharge  had  ceased.  On 
the  sixth  day  the  patient  was  dismissed  cured. 

It  is  not  at  all  uncommon  to  find  the  sinus  of  an  alveolar  abscess 
venting  itself  somewhere  on  the  cheek.  This  is  too  frequently  the 
result  of  inviting  the  matter  to  the  surface  by  the  warm  applications 
made  to  the  side  of  the  face.  When  pus  thus  seeks  the  surface  it 
should  be  vented  from  the  inside.  While  support  to  the  parts 
toward  which  it  is  pointing  is  to  be  given  by  means  of  a  compress 
saturated  with  a  refrigerating  styptic,  alum-  or  lead-water  being 
indicated, — anything  answering  the  purpose  which  tends  to  con- 
tract or  shrivel  the  skin, — a  plain  compress  is  never  to  be  used,  as 
this  expedites  the  absorption  which  the  indication  is  to  abort.  The 
puncture  of  such  an  abscess  is  a  very  simple  matter,  and  will  fre- 
quently be  successful  if  the  pus  should  have  found  its  way  even  so 
far  externally  as  to  have  but  the  skin  between  it  and  the  atmosphere. 
Care  must,  however,  be  taken  not  to  wound  the  facial  artery  or  the 
duct  of  Steno. 

Abscesses,  associated  with  the  wisdom  teeth,  sometimes  pass  in 
the  direction  of  the  parotid  region ;  in  these  cases  it  is  not  uncom- 
mon to  find  the  orifice  of  the  fistule  as  low  down  as  the  clavicle,  the 
unyielding  character  of  the  parotid  fascia— a  continuation,  as  it  will 
be  remembered,  of  the  deep  cervical — compelling  this  lengthened 
dissection. 

A  form  of  alveolar  abscess,  which  may  lead  to  false  diagnostic 
premises,  exists  in  cases  where,  from  the  relation  of  a  diseased 
fang  with  the  maxillary  sinus,  the  discharge  empties  itself  into  this 
cavity,  to  be  in  turn  voided  into  the  naris.  (See  Diseases  of  An- 
trum.) 

Another  and  indeed  very  curious  result  of  alveolar  abscess  is  the 
formation  of  osseous  cysts  on  the  side  of  the  jaws;  the  pus,  instead 
of  inducing  the  ordinary  absorption,  is  provided  for  by  the  expan- 
sion of  the  outer  plate  of  the  bone.  These  cysts  give  little  or  no 
sense  of  fliuctuation  or  crackling  on  pressure.  There  is  no  appear- 
ance of  surrounding  inflammation;  the  soft  parts  covering  them  do 
not  differ  in  any  respect  from  the  adjoining  tissue.  I  have  found 
such  cysts  or  tumors  generally  associated  with  teeth  in  which  the 
pulps  have  been  destroyed  and  the  fangs  filled  with  metal.  They 
form  sometimes  very  rapidly, — that  is,  when  compared  with  tumors. 


THE   TEETH  AND    THEIR  DISEASES.  175 

for  which  they  may  be  mistaken.  I  have  treated  them  where  the 
cyst  has  enlarged  to  the  size  of  a  half  hickory-nut  in  a  few  months. 
This  rapid  growth  is  particularly  diagnostic.  The  easiest  treatment 
of  such  cysts  would  be  of  course  the  extraction  of  the  ofl'ending 
tooth  ;  but  they  are  also  to  be  cured  by  opening  them  transversely 
and  stuffing  the  cavity  with  lint  saturated  with  tincture  of  iodine, 
or  some  other  stimulant ;  the  cyst  is  thus  obliterated,  and  the  sac  at 
the  end  of  the  fang  destroyed,  through  the  healthy  reaction  which 
the  treatment  excites.  These  cysts  are  not  to  be  confounded  with 
the  sub-periosteal  exudates  frequently  found  overlying  the  site  of 
diseased  roots. 

Mr.  Smith,  in  illustrating  a  lecture  on  alveolar  abscess,  notices 
the  following  cases  from  his  practice: 

A  few  years  ago,  he  says,  a  middle-aged  man  asked  his  opinion  about 
a  fistulous  sore  which  opened  on  the  middle  of  his  whisker  of  the  right 
cheek.  Mr.  S.  introduced  a  probe,  and  finding  that  it  came  in  contact 
with  the  fang  of  the  last  molar  tooth  of  the  upper  jaw,  persuaded 
the  patient  to  allow  him  to  extract  it,  on  the  promise  that  he  should 
be  well  in  a  few  days.  On  the  tenth  day  the  gentleman  wrote,  by 
post,  to  say  that  the  discharge  ceased  the  day  the  tooth  was  extracted, 
and  that  at  the  time  of  writing  it  was  perfectly  well. 

He  relates  the  case  of  a  young  woman  who  came  under  his  charge 
at  the  infirmary,  with  a  fistulous  sore  in  the  fore  part  of  the  throat, 
within  an  inch  of  the  sternum.  It  had  been  discharging  upwards  of 
a  year.  On  probing  it,  the  instrument  could  be  passed  in  the  direc- 
tion of  the  molar  of  the  lower  jaw  on  the  left  side.  On  inquiry,  the 
patient  said  that  eighteen  months  before  she  had  a  tooth  drawn, 
but  the  fangs  had  been  left  in  the  jaw.  Afterward  an  abscess 
formed,  which  descended  lower  and  lower  until  it  burst  midway 
between  the  sternum  and  pomuni  Adami.  Mr.  S.  extracted  the 
stump,  it  still  discharged  for  a  week,  when  it  got  well  without  other 
treatment. 

Mr.  S.  alludes  also  to  a  case  where  a  horse  had  been  condemned 
to  the  knacker's  yard,  as  being  afflicted  with  the  glanders,  having  a 
foul,  offensive  discharge  of  purulent  matter  from  the  nostrils,  and 
being  in  the  last  stage  of  emaciation.  A  veterinary  surgeon,  finding 
that  it  could  not  masticate  its  food,  examined  its  mouth,  and  detect- 
ing a  carious  tooth  in  the  upper  jaw,  extracted  it.  The  discharge 
ceased ;  the  horse  soon  began  to  thrive,  ftnd  got  well. 

Mr.  Fieischraan  (Britiah  Medical  Journal)  relates  the  following 
example:  "Miss  Rose  S.,  a  little  girl,  aged  five  years,  had  been 


176  ORAL  DISEASES  AND   SURGERY. 

troubled  about  three  months  with  a  constant,  though  not  profuse, 
discharge  of  slightly-purulent  mucus  from  the  right  nostril ;  it  ap- 
peared to  be  the  sequel  of  a  cold.  The  mucous  membrane,  so  far  as 
it  could  be  examined,  was  healthy,  and  there  were  no  indications  of 
any  morbid  growth.  She  was  ordered  a  strong  injection  of  gallic  acid, 
and  took,  concurrently,  small  doses  of  the  sesquichloride  of  iron.  The 
only  advantage  she  derived  was  that  the  discharge  lost  its  purulent 
character ;  in  amount  it  remained  about  the  same,  though  the  treat- 
ment was  long  persevered  in  and  other  local  astringents  tried.  I 
suspected,"  says  Mr.  F.,  "there  must  be  some  undiscovered  local 
irritation.  Not  being  able,  on  careful  examination,  to  find  anything 
wrong  in  the  nasal  passages,  I  looked  to  the  condition  of  the  teeth, 
and  finding  the  right  upper  canine  carious,  removed  it.  The  dis- 
charge was  much  lessened  on  the  next  day,  and  in  the  course  of  a 
day  or  two  disappeared  altogether." 

Mr.  Fleischman,  although  he  does  not  seem  to  see  that  his  case  is 
simply  one  of  alveolar  abscess,  but  offers  it  as  "a  good  illustration 
of  reflected  irritation,"  truly  remarks  that  it  "  teaches  us  that  the 
fons  et  origo  mali  is  not  always  just  where  we  might  expect  to 
find  it." 

I  have  had,  in  my  own  practice,  several  cases  where  the  pus  of 
an  alveolar  abscess  discharged  itself  from  the  nares;  but  the  dis- 
ease, in  every  case  in  which  I  have  seen  it,  where  the  sinus  passed 
in  such  direction,  was  associated  with  the  central  incisor  teeth.  It 
is,  however,  to  be  inferred  that  other  of  the  teeth  might  associate 
sinuses  with  the  posterior  aspect  of  the  nares,  dripping  their  dis- 
charge behind  the  veil  of  the  soft  palate,  a  number  of  such  cases 
being  indeed  on  record. 

Abscesses  of  this  nature  are  not  unfrequently  associated  with  the 
eruption  of  the  wisdom  teeth.  The  arch  being  too  small  to  accom- 
modate the  advancing  organ,  it  becomes,  as  a  matter  of  necessity,  an 
agent  of  irritation;  inflammations  of  the  most  severe  nature  are  thus 
oftentimes  provoked,  inducing,  too  commonly,  trismus  and  abscess. 
(See  Trisviuii  Deutium.)  Abscesses  from  this  cause  generally  dis- 
charge about  the  neck  of  the  tooth;  they  may,  however,  void  them- 
selves in  other  situations,  as,  for  example,  upon  the  face  or  neck,  A 
case  illustrative  comes  this  moment  to  my  mind: — Dr.  D.,  a  medical 
gentleman,  suffered  for  some  time  with  heavy,  dull  pain  in  the  right  ; 
half  of  his  lower  jaw,  and  which  was  attributed  to  two  of  his  teeth, 
much  decayed,  but  which,  however,  had  been  treated  and  plugged. 
Inflammation  of  a  severe  character  finally  developed,  and,  in  defiance 


TBE   TEETH  AND    THEIR  DISEASES.  177 

of  all  treatment,  I'an  on  to  abscess,  which  abscess  discharged  upon 
the  cheek.  The  pus  voided,  relief,  of  course,  was  obtained.  The 
sinus,  however,  continued  to  discharge,  and,  at  the  time  of  my  being- 
consulted,  the  ulcer  had  become  a  source  of  much  annoyance  as  well 
as  deformity.  This  case  had  been  examined  by  various  friends  of 
the  gentleman,  and,  while  all  pronounced  it  alveolar  abscess,  all 
associated  it  with  the  treated  teeth.  The  removal  of  a  developing 
wisdom  tooth,  a  single  cusp  alone  of  which  presented,  caused  the 
fistule  to  heal  in  a  single  week.  A  complication  sometimes  met 
with  in  abscess  discharging  upon  the  cheek,  and  of  which  it  is  most 
important  that  note  should  be  taken,  consists  in  a  relation  of  the 
sinus  with  the  duct  of  Steno.  I  have  in  the  past  few  years  met 
with  a  number  of  cases  of  this  nature,  and  by  the  operation  required 
for  salivary  fistula  have  been  enabled  readily  to  cure  them  after  the 
failure  of  every  device  not  entertaining  an  appreciation  of  such  condi- 
tion. It  is  to  be  impressed  that  such  fistulas  deceive  in  the  very 
limited  salivary  discharge,  thig  fluid  being  easily  overlooked  in  its 
relation  with  the  pus  ;  my  experience  would  lead  me  to  infer  that  the 
opening  into  the  duct  may  not  unfrequently  be  of  the  most  diminu- 
tive calibre.  Where  such  a  case  is  recent,  it  is  proper  to  attempt  a 
cure  through  the  granulative  process,  trusting  by  such  means  to  cover 
in  the  break  of  the  duct ;  to  accomplish  this,  no  better  means  may  be 
employed  than  daily  touching  the  parts  with  tincture  of  iodine  or 
with  crystals  of  the  chloride  of  zinc,  it  being  of  course  understood 
that  the  dental  relation  of  the  disease  has  been  previously  cured. 
If  such  means  fail,  and  this  will  be  found  the  most  likely,  then  an 
operation  is  required.  (See  Salivary  Fistule.) 

Alveolar  abscess  also  not  unfrequently  exists  where  the  discharge 
is  exclusively  through  the  foramen  of  the  tooth,  this  orifice  being 
enlarged.  The  gums  in  these  cases  may  be  unaffected,  affording  no 
•signs  of  disease,  the  evidence  of  the  discharge  being  perhaps  alone 
in  a  peculiarly  disagreeable  taste  experienced  by  the  patient.  To 
cure  these  cases,  it  may  be  sufficient  to  throw  the  required  injec- 
tion through  the  canal  of  the  tooth  ;  but,  should  this  fail,  the  method 
of  entering  the  cyst  through  the  alveolus  is  to  be  tried.  To  so 
enter  such  a  cyst,  a  very  delicate  trephine  may  be  employed,  or, 
what  commonly  answers  every  purpose,  a  spear-shaped  drill  may  be 
used.  Incising  the  gum  over  the  apex,  the  drill  is  simply  to  be 
rotated  into  the  cyst;  precaution,  however,  is  to  be  taken  that  none 
of  the  bony  particles  be  allowed  to  remain,  adding  their  quota  of 
offense.     This  is  guarded  against  by  the  free  use  of  the  syringe. 

12 


178  ORAL  DISEASES  AND  SURGERY. 

An  alveolar  discharge,  which  may  be  termed  false  abscess,  is  met 
with  frequently  in  association  with  alveoli  into  which  salivary  cal- 
culus is  intruding.  In  these  cases  no  difficulty  is  to  be  experienced 
in  the  diagnosis;  the  discharge  is  seen  about  the  necks  of  the 
affected  teeth,  the  gum  is  more  or  less  puffy,  and  the  irritating  de- 
posit is  evident  enough.  To  cure  cases  of  this  kind,  it  is  commonly 
necessary  only  to  scale  or  cut  away  the  offending  agent,  and,  after 
making  a  few  incisions  through  the  congested  and  debased  gum, 
stimulate  the  parts  by  such  applications  as  may  seem  indicated. 
Few  medicaments  are  more  reliable  in  this  direction  than  the  dilute 
aromatic  sulphuric  acid,  or  this  combined  in  equal  proportions  with 
the  tincture  of  capsicum.  It  is  found,  however,  not  unfrequently 
the  case  that  the  deposit  has  so  destroyed  the  sockets  of  the  teeth 
that  no  cure  is  possible  outside  of  extraction.  (See  Salivai'y  Cal- 
culus.) 

Chronic  alveolar  abscess,  resisting  local  treatment,  is  to  be  viewed 
commonly  as  of  constitutional  association.  In  persons  who  are 
laboring  under  the  effects  of  a  mercurial  poisoning,  the  cases  are 
found  most  resistive  ;  indeed,  in  many  instances,  it  is  felt  to  be  use- 
less to  make  any  attempt  to  save  the  affected  teeth,  the  organs  being 
absolutely  thrust  from  their  sockets  and  falling  into  the  mouth. 
Where  not  too  loose,  however,  the  gums  are  to  be  incised  every  few 
days  in  the  vertical  direction,  and  attempts  made  to  resolve  the 
turgidity  and  puffiness  by  paintings  of  the  tincture  of  iodine  and 
capsicum,  alternated  with  washes  of  chlorate  of  potash  and  cologne. 

B. — Potassae  chloratis,  3ss; 
Aquae  Colon.,  5j ; 
AquEe,  §vij.  M. 

Sig.  Use  many  times  daily. 

Internally  the  chlorate  of  potash  may  be  directed  in  doses  of 
fifteen  grains,  repeated  three  times  daily. 

R. — PotassiB  chloratis,  Jiij ; 
Aquae,  sviij.  M. 

Sig.  Tablespoonful  as  a  dose. 

The  rheumatic  diathesis  is  to  be  recognized  as  at  least  a  predis- 
posing cause  to  alveolar  abscess,  and  one  which  at  times  forces 
itself  upon  attention  in  treatment  of  the  condition.     As  this  toxical 


THE   TEETH  AND    THEIR  DISEASES.  179 

influence  is  recognized  as  having-  aflSnity  with  periosteal  tissue,  so 
there  is  no  reason  to  doubt  that  occasionally  it  is  the  resistive  agent 
in  the  cure  of  such  conditions.  A  similar  view  will  also  be  found 
to  hold  good  of  the  malarial  poisons,  and,  indeed,  it  very  well  may 
be,  of  all  the  other  toxical  conditions.  Not  at  all  that  it  is  to  be 
afiBrmed  that  such  poisons  have  necessarily,  in  all  instances,  a  direct 
relation,  but  that,  being  depressent  to  the  system  at  large,  they 
antagonize  that  reparative  influence,  without  which  the  parts  may 
not  restore  themselves;  precisely,  if  an  illustration  be  needed,  as 
a  venereal  ulcer,  however  proper  and  vigorous  the  local  treatment, 
refuses  to  be  made  well  until  systemic  influences  are  considered  and 
antagonized. 

Gout  is  another  constitutional  predisposition  to  chronicity  in 
alveolar  abscess,  just  as  it  is  a  frequent  excitant  to  pulpitis ;  and  an 
abscess  which  refuses  to  respond  to  any  direct  medication  yields, 
with  such  predisposition,  to  a  few  doses  of  colchicum.  Defying 
abscesses  of  this  nature  are  oftentimes  found  to  give  way  to  the 
alterative  influence  of  a  week  at  the  seashore,  or  a  trip  to  the 
mountains. 

In  chronic  abscess  the  discharge  must  necessarily  continue  so  long 
as  the  periodonteum  remains  in  its  pathological  state.  It  is  there- 
fore always  necessary  in  association  with  any  systemic  treatment 
which  it  may  be  desirable  to  adopt,  to  break  up  the  local  condition. 
To  accomplish  this,  no  better  means  can  be  employed  than  to  tear 
the  sac  to  pieces  by  means  of  a  delicate,  soft  excavator  passed 
through  the  sinus.  After  such  breaking  up  of  the  sac,  the  part  is  to 
be  syringed  daily  with  an  aqueous  or  vinous  dilution  of  the  ordi- 
nary officinal  tincture  of  iodine, — about  half  and  half  of  either  being 
a  good  proportion.  Another  most  excellent  agent  is  found  in  the 
chloride  of  zinc.  Of  this  salt,  a  solution  of  three  grains  to  the 
ounce  of  water  may  be  employed,  a  tent  of  cotton  being  saturated 
and  carried  into  the  cyst,  or,  charging  with  a  few  drops  the  ordinary 
hypodermic  syringe,  the  fluid  may  be  thrown  into  the  sinus.  Other 
local  medicaments  are  found  in  nitrate  of  silver,  sulphate  of  copper, 
tincture  of  capsicum,  permanganate  of  potash,  in  the  passage  of  the 
electro-galvanic  current,  in  carbolic  acid,  in  creasote,  in  alcohol,  et 
hoc  genus  omne. 

Where  an  abscess  discharges  itself  exclusively  through  the  pulp 
canal,  the  very  best  plan  of  treatment  is  to  make  a  counter-opening 
in  the  gum  and  proceed  as  directed  for  the  abortion  of  the  acute  state 
of  the  disease,  using,  besides,  injections  and  tents  until  all  discharge 


180  OEAL  DISEASES  AND   SURGERY. 

ceases;  or,  if  objection  exists  to  this,  it  will  sometimes  be  found  to 
answer  to  carry  into  the  canal  threads  of  silk  saturated  with  the 
medicament  selected.  Another  and  a  better  mode  than  the  use  of 
the  threads  is,  however,  to  introduce  into  the  canal  a  plug  of  gutta 
percha,  in  which  a  hole  is  to  be  made  of  a  size  just  sufficient  to  re- 
ceive the  nozzle  of  a  delicate  syringe.  Thus  directed  and  controlled, 
injections  may  be  forced  through  the  foramen.  Any  treatment, 
however,  except  that  by  the  counter-opening,  will  seldom  be  found 
satisfactory. 

A  tooth  having  such  discharge  through  its  canal,  and  thus  inca- 
pable of  bearing  a  filling,  may  have  such  filling  retained  without 
response  by  making  the  counter-outlet  through  the  alveolar  wall. 
Such  a  treatment  I  have  frequently  adopted  with  much  satisfaction, 
having  success  in  saving  the  tooth  where,  without  the  puncture 
made  through  the  gum  and  bone,  thecavit}^  would  not  have  endured 
the  plug  for  half  an  hour. 

An  explanation  of  chronic  alveolar  abscess  where  no  medication 
can  possibly  avail  is  found  sometimes  in  a  twist  of  gold  which  has 
been  thrust  through  the  foramen  in  the  act  of  filling  the  root.  With 
this  cause  I  have  several  times  met,  although  never  appreciating  it 
until  exhibited  in  the  extracted  tooth. 

An  alveolar  abscess  connected  with  the  teeth  of  scrofulous  chil- 
dren will  not  unfrequently  result  in  a  necrosis  exfoliating  the  sur- 
rounding process.  A  case  of  this  kind,  coming  quite  lately  under 
my  notice,  resulted  in  the  loss  of  quite  half  of  the  right  superior 
maxilla;  while  a  second  case,  occurring  in  a  mercurialized  man, 
destroyed  the  whole  bone. 

A  chronic  alveolar  abscess  is  not  unfrequently  found  resistive  to 
treatment  as  the  result  of  the  mechanical  cause  of  a  malarticulation, 
which  keeps  the  affected  tooth  continuously  worried.  This  is  an 
offense  for  which  we  are  always  to  examine,  as  it  is  readily  induced 
by  changes  which  may  have  occurred  from  the  inflammatory  asso- 
ciations. Any  single  tooth,  however  healthy,  striking  in  its  artic- 
ulation before  its'  fellows,  will  become  thereby  diseased.  This  is 
often  enough  witnessed  where,  in  filling  teeth,  the  metal  has  not 
been  sufficiently  dressed  down,  and  is  thus  unduly  impinged  upon; 
such  teeth  becoming  sore  to  the  touch,  even  to  the  result,  when 
the  cause  is  not  appreciated  and  removed,  of  irritating  the  part 
into  abscess. 

Abscess  associated  with  the  temporary  teeth  is  always  to  be 
looked  on  with  concern,  the  irritability  and  excitability  of  the  young 


THE   TEETH  AND    THEIR   DISEASES.  181 

jaw  being  so  great  that  any  addition  to  the  excitation  of  the  dentinal 
period  is  found  commonly  to  prove  more  than  the  force  of  the  parts 
can  antagonize, — thus  resulting  not  unfrequently  in  extensive  dis- 
organizations. Should  abscess  in  the  temporary  tooth  have  asso- 
ciation with  any  of  the  exanthems,  the  immediate  removal  of  the 
organ  is  made  a  necessity.  Indeed,  these  infantile  abscesses,  how- 
ever associated,  are  never  to  be  allowed  to  run  on,  but,  if  not  speedily 
responsive  to  medication,  should  be  cured  by  extraction  of  the 
offending  tooth  or  teeth. 

As  is  involved  the  principle  in  the  treatment  of  an  alveolar 
abscess,  it  is  required  simply  that  the  practitioner  recognize  pus  as 
protoplasmic  degeneration  :  matter  breaking  down  because  of  an 
inability  to  organize  into  living  tissue.  Whatever  shall  afford  or 
add  the  lost  force  must  prove  the  cure  of  the  abscess.  To  this  end 
all  deteriorative  local  causes  of  offense  are  to  be  removed.  If  a  tooth 
contain  a  dead  pulp,  such  pulp  is  to  be  extirpated  ;  if  it  unduly 
strike  its  neighbor,  as  just  alluded  to,  such  false  occlusion  is  to  be 
remedied  ;  if  irritation  be  kept  up  by  subjection  of  the  membrane 
to  foreign  agents  of  offense,  as  a  habit  of  biting  improper  articles, 
cracking  nuts,  untying  knots,  cutting  threads,  etc.,  subjection  of  the 
parts  to  rapid  and  great  alternations  of  heat  and  cold,  as  in  the  use 
of  ices  and  hot  drinks,  these  and  any  other  causes  of  offense  are  to 
have  consideration. 

General  indications  are  to  restore  healthy  innervation,  circulation, 
secretion,  and  excretion,  by  such  medication,  hygienic  or  otherwise, 
as  shall  tend  to  allay  irritation,  increase  plasticity  through  tonicity, 
and  restore  normal  action.  To  such  an  end,  besides  the  local  medi- 
cation which  may  be  required,  resort,  as  indicated,  may  be  compelled 
to  the  employment  of  specifics,  nervines,  alteratives,  astringents,  and 
antiseptics.  In  one  sentence,  we  are  to  recognize  and  appreciate 
the  indications,  local  and  general,  and  meet  them.  When  this  has 
been  done,  and  yet  a  cure  is  not  secured,  the  only  remaining  ques- 
tion is  between  the  extraction  of  the  affected  tooth  or  teeth,  and 
the  risk  of  such  consequences  as  osseous  caries  or  necrosis. 


CHAPTER   IX. 

THE    TEETH    AND    THEIR   DISEASES. 
ANCHYLOSIS  OF  THE  JAW. 

Under  the  heading  of  diseases  of  the  teeth  we  may  study  the 
subject  of  anchylosis,  inasmuch  as  in  a  knowledge  of  the  associate 
lesions  of  these  organs,  in  such  direction,  we  seem  to  start  from  the 
most  elementary  foundation. 

Anchylosis  of  the  iaw(ayxu).o<;,  crooked),  trismus  (r/)jCw,  to  gnash), 
finds  its  general  nature  and  characteristics  exhibited  in  the  condition 
as  seen  in  the  common  articular  system.  A  special  study  may 
therefore  be  beneficially  preceded  by  a  review  of  the  subject  at  large. 

By  anchylosis  is  meant  stiS'ness  in  an  articulation,  such  stiffness 
varying  to  absolute  immobility.  The  terms  true  and  false,  complete 
and  incomplete,  are  emploj^ed  to  express  two  common  groups  under 
which  a  variety  of  forms  are  classed ;  the  first  being  applied  to  a 
state  of  fixedness  in  the  joint,  the  second  where  more  or  less  motion 
exists.  A  clinical  division,  however,  and  one  the  practical  utility 
of  which  every  practitioner  is  soon  found  to  recognize,  is  consideration 
of  the  lesion  as  reference  is  had  to  its  intra-  or  extra-articular  char- 
acter; that  is,  whether  the  disease  is  within,  or  without,  the  joint. 

Intra-articular  anchylosis  implies  change  in  the  articular  relations, 
arthritic  inflammatory  action  leading  to  plastic  effusion,  which  effu- 
sion has  necessarily  a  varying  history.  Imprimis,  a  stiff  joint  may 
depend  on  a  simple  sj'novitis  ;  the  ease  of  the  patient  compelling 
quietude  in  the  part.  It  may  associate,  again,  with  lengthened 
disuse  of  the  joint,  as  compelled  in  fracture-treatment,  such  fixed- 
ness acting  as  the  abstraction  of  the  natural  stimulus  of  the  part 
found  in  its  motion,  thus  resulting  in  a  dryness  which  becomes  in 
time  the  excitant  of  an  inflammatory  exudate,  with  tendency  to 
organization  favored  by  the  immobility.  Arthritic  inflammatory 
action  is  the  history  of  all  inflammatory  action,  and  is  to  have  con- 
sideration from  such  common  standpoint. 

In  any  inflammation,  a  matter  which  first  calls  for  consideration  is 
(182) 


THE    TEETH  AND    THEIR  DISEASES.  183 

the  character  and  nature  of  the  disturbance.  Such  a  consideration 
applies  particularly  t,o  arthritis  ;  for  whether  the  action  arises  from 
local  or  constitutional  causes  makes  nearly  all  the  difference  in  such 
prognosis  as  we  may  feel  inclined  to  offer. 

Local  arthritis  is  expressed  by  any  cause  of  offense  of  local  char- 
acter that  may  be  discovered  to  have  provoked  the  lesion  ;  of  such 
offenses  we  may  instance  blows,  luxations,  fractures,  immediately 
neighboring  lesions,  inter-articular  bodies. 

Arthritis  of  constitutional  relation  finds  its  diagnosis  in  the  ab- 
sence of  local  sources  of  offense,  and  in  the  presence  of  cachexia: 
scrofulosis,  syphilis,  rheumatism,  gout,  cancer,  and  the  sang  calcine. 
The  rheumatic,  gouty,  and  scrofulous  arthrosia  are  very  familiar 
exhibitions  in  such  a  direction. 

Complicated  Arthritis. — This  refers  to  a  provocation  into  action, 
by  some  local  irritant,  of  an  abeyant  cachexia.  Enough  instances  of 
such  complications  are  found  in  the  hip  diseases  of  children  arising 
from  falls,  and  of  cancers  located  through  local  injuries. 

Inflammation  in  a  joint  has  primarily  a  double  diagnostic  signifi- 
cation of  much  concern  to  the  surgeon;  that  is,  the  inflammation  may 
involve  the  joint  proper,  bones,  cartilages,  or  synovial  membrane ; 
or  it  may  be  confined  to  the  latter  exclusively. 

In  synovitis  proper,  the  prognosis  is  much  more  favorable  than  in 
true  arthritis,  provided  the  attack  be  acute  in  character  and  the 
treatment  timely.  Synovitis  in  its  incipiency  is  attended  by  excess 
in  the  natural  seci'etion  of  the  membrane,  associated  with  more  or 
less  serum ;  such  excess,  by  overfullness  of  the  articular  cavity,  inter- 
fering markedly  with  freedom  of  motion.  Passing  into  a  chronic 
state,  the  neighboring  parts  are  soon  involved,  and  what  is  to  be  the 
result  depends  as  much  on  the  circumstances  of  the  case  as  on  the 
care  and  skill  employed  in  the  treatment.  Efl'usions  in  synovitis  are 
readily  distinguished,  the  serous,  associated  with  all  the  phenomena 
of  acute  inflammation, — the  parts  being  red,  heated,  painful,  elastic, 
and  fluctuating.  The  plastic  exudate,  appearing  after  the  acute 
action  has  passed,  is  dull,  doughy,  and  pitting,  and  divested  of  active 
associations. 

An  attack  of  synovitis  may  be,  and  indeed  commonly  is,  sub- 
acute in  character,  that  is,  it  may  be  a  long  while  in  developing 
itself,  and  this,  even  when  it  is  the  result  of  local  injury.  The  first 
symptom  attracting  notice  is  apt  to  be  a  sense  of  stiffness  after  rest, 
this  being  most  observed  in  the  morning;  succeeding  this  is  pain, 
with  the  stift'ness  prolonging  and  fixing  itself;  swelling  will  now 


184  ORAL  DISEASES  AND   SURGERY. 

perhaps  be  first  observed,  the  heat  of  the  part  increasing-  with  the 
distention  ;  suffered  to  progress,  suppuration  of  the  membrane  may 
be  the  result,  and  with  it  the  complete  destruction  of  tbe  joint.  A 
better  and,  happily,  more  frequent  result  is  found  in  a  cure  of  the 
inflammation  through  the  exudative  process,  such  exudation  seem- 
ing to  afford  the  necessary  relief  to  the  over-distended  vessels. 
With  such  a  result  obtaining,  the  care  of  the  surgeon  becomes 
directed  alone  to  the  exudate,  the  absorption  of  the  serum  is  to  be 
compelled,  and  through  passive  motion  and  the  judicious  employ- 
ment of  the  sorbefacients,  the  plastic  lymph  may  not  be  allowed  to 
associate  its  bands  with  parts  that  shall  afford  it  the  capability  of 
organization. 

Acute  synovitis,  if  disassociated  with  cachexia,  may  commonly 
be  quickly  resolved  into  a  subacute  condition;  to  obtain  such  result, 
however,  treatment  is  to  be  directed  with  much  judgment ;  if  purely 
local,  the  attention  required  will  most  likel}^  be  one  vigorously  anti- 
phlogistic;* if  conjoined  with  cachexia,  local  sedation  is  to  have 
associated  with  it  a  cionstitutional  specific  medication,  or  a  treatment 
of  stimulation  and  invigoration  as  may  be  indicated.  A  common 
treatment  for  an  acutely  inflamed  joint,  whatever  the  parts  involved, 
might  be  laid  down  as  follows:  Put  the  feet  and  legs  in  water,  as 
hot  as  can  be  borne;  administer  a  full  saline  cathartic,  or  a  diapho- 
retic; apply  a  lead-water  and  laudanum  lotion  to  the  inflamed  part; 
bleed  with  the  lancet,  or,  locally,  by  leeches;  depress  the  circulatory 
force  by  the  administration  of  arterial  sedatives,  and  restrict  to  a  low 
diet;  use  counter-irritants;  any  or  all  of  these  means  being  employed 
according  to  the  indications  of  the  case,  an  exception  to  the  use  of  the 
pediluvium  existing  in  inflammation  of  the  inferior  joints.  An  inflam- 
mation, having  its  acuteness  broken,  is  often  happily  terminated  by 
painting  the  parts  with  the  tincture  of  iodine,  or  with  the  muriated 
tincture  of  iron  combined  with  quinine  and  the  tincture  of  cinchona, 
as  recommended  on  another  page  for  erysipelas,  or  with  diluted 
Monsel's  solution  of  the  persulphate  of  iron,  and  afterwards,  if 
deemed  necessary,. enveloping  the  part  in  the  lead  and  laudanum 
lotion.  Where  structural  change  is  feared  as  the  result  of  eflnsions, 
the  mercurials  may  be  administered  and  pushed  to  the  least  percep- 
tible evidence  of  their  impression.  It  is  seldom  the  case,  however, 
that  a  result  is  not  better  without  than  with  these :  it  is  not  to  be 

*  A  cure  almost  magical  in  the  rapidity  witli  which  it  results  is  sometimes 
secured  by  cauterizing  the  surface  with  the  solid  nitrate  of  silver. 


THE   TEETH  AND    THEIR    DISEASES.  185 

doubted  that  through  the  injudicious  use  of  this  medicine  many 
joints  have  been  depressed  to  suppuration,  which,  without  it,  would 
have  escaped. 

When,  in  defiance  of  treatment,  suppuration  occurs' in  a  joint, 
the  pus  formed  is  to  be  got  clear  of  as  speedily  as  possible.  To 
effect  this,  it  is  perhaps  not  possible  to  adopt  a  better  plan  than  the 
subcutaneous  valvular  puncture,  to  be  made  by  using  a  delicate 
tenotome.  Such  a  valve  may  be  opened  as  often  as  the  pus  reaccu- 
mulates.  At  this  stage  it  is  also  that  we  may  resort  to  direct  stim- 
ulation with  prospects  of  good  results.  Yet  what  is  to  be  the  precise 
nature  and  extent  of  such  stimulation  is  not  so  easy  to  suggest,  each 
case  having,  most  likel}^  some  special  indication.  The  principle 
of  the  means,  however,  would  be  found  in  anything  that  should 
arouse  the  parts  to  a  higher  and  healthier  grade  of  action;  stimu- 
lating embrocations,  hot  or  cold  douches,  strapping,  painting  as 
before  suggested,  passive  motion,  or  even,  it  might  very  well  be,  in- 
jections into  the  joint  itself,^— a  means  that  might  save  the  articula- 
tion where  all  others  should  fail. 

Synovitis  having  a  systemic  origin  demands  that  the  treatment 
consider  the  specific  indications.  If  syphilitic,  gouty,  rheumatic,  or 
strumous,  medicines  which  experience  characterizes  as  most  antago- 
nistic to  these  conditions  must  be  conjoined  with  the  local  means. 
Thus,  while  giving  every  attention  to  the  affected  joint,  we  direct 
a  medication  to  the  cause  at  large. 

Arlhritis. — By  arthritis  is  meant  the  inflammation  of  the  common 
structures  of  the  joint;  here  the  danger  of  ill  results  is  proportion- 
ally greater  than  synovitis  as  extent, of  parts  is  involved.  An 
arthritic  inflammation  may  be  general,  involving  all  the  components 
of  a  joint,  and  of  such  severity  of  grade  as  to  run  quickly  into  sup- 
puration and  destruction  of  the  parts,  or,  on  the  contrary,  it  may 
prove  so  slight  as  not  to  amount  to  anything  more  grave  than  a 
temporary  congestion  resolvable  by  a  few  hours  of  rest  and  seda- 
tion. Between  these  two  extremes  are  found  all  the  phenomenal 
associations  of  inflammatory  action.  An  arthritis  in  the  fullness  of 
its  history  might  be  thus  described:  First,  a  sense  of  stiffness  in 
the  joint,  with  increasing  uneasiness, — the  stage  of  simple  vascular 
excitement.  Second,  the  development  of  the  sense  of  heat,  the  parts 
swelling  and  becoming  intensely  painful  on  the  slightest  motion, — 
the  stage  of  active  congestion.  Third,  fixed  engorgement,  the  pain 
persistent  and  of  a  heavy  character,  skin  a  dull  red  or  white,  accord- 


186  .        ORAL  DISEASES  AND  SURGERY. 

ing  as  the  inflammation  may  or  may  not  have  traveled  to  the  sur- 
face,— the  stage  of  stagnation.  Fourth,  the  destruction  and  breaking 
down  of  the  involved  parts, — necrosis,  as  evidenced  in  morbus  cox- 
arius, — the  stage  of  suppuration  and  devitalization.  Fifth,  hectic 
fever  from  exhaustion,  or  pyemia  from  pus  poisoning.  Sixth,  death. 

The  treatment  of  arthritis  proper  is  precisely  that  indicated  and 
employed  in  synovitis.  To  limit  and  control  inflammatory  action 
is  the  principle  of  the  cure.  The  vigor  with  which  such  a  treat- 
ment is  to  be  directed  depends,  of  course,  on  the  indications  of  each 
special  case,  these  presenting,  as  suggested,  every  shade  of  char- 
acter. If  an  inflammation,  in  deflance  of  the  immediate  antago- 
nists employed  for  its  control,  pass  onward  in  its  grade  to  the 
efi'usion  of  lymph,  as  recognized  by  the  doughy,  pitting  character  of 
surrounding  parts,  then  the  danger  of  anchylosis,  on  the  one  hand, 
or  of  the  degeneration  of  this  agent  into  pus,  on  the  other,  is  the 
matter  which  presses  for  attention  and  concern.  Passive  motion 
of  the  gentlest  character  is  to  be  resorted  to,  together  with  the 
employment  locally  of  sorbefacients,  combined  with  such  general 
medication  as  the  particular  case  may  appear  to  demand.  If  the 
mercurials  seem  essential,  the  practitioner  will  seldom  find  himself 
at  fault  in  combining  tonics  with  them.  This  will  most  certainly 
be  found  to  hold  true  in  all  cases  associated  with  asthenia.  Tlie 
character  of  cases  in  which  it  would  seem  to  ray  judgment  that  the 
mercurials  are  admissible,  and,  indeed,  in  some  instances,  positively 
necessary,  is  that  where  the  trouble  occurs  with  the  robust  and 
vigorous.  In  cases  of  this  class  their  good  effects  are  occasionally 
markedly  observed ;  but  even  here,  if  they  be  employed  too  freely, 
the  harm  done  quickly  overbalances  the  good.  When  a  mercurial 
is  used,  the  effects  produced  are  to  be  watched  with  the  closest 
attention,  and  never  is  it  to  be  inferred  that,  because  good  eflects  are 
observed  from  the  gentlest  of  ptyalisms,  a  pushing  of  the  medicine 
will  expedite  the  cure.  No  greater  error  than  this  can  arise ;  a  result 
is  not  unapt  to  be  pus,  and  the  destruction  of  the  joint.  Another 
matter,  not  to  be  overlooked  in  the  employment  of  this  medicine,  is 
its  cumulative  nature.  A  man  may  take  a  mercurial  for  a  week  or 
a  month  without  apparent  effect,  when  suddenly  the  most  profuse 
ptyalism  will  exhibit  itself  I  have  seen  this  again  and  again  with 
patients  under  treatment  for  syphilis. 

Rheumatoid  Arthritis. — For  a  medical  paper  treating  most  fully 
on  this  condition,  the  reader  is  referred  to  Reynolds's  System  of 
Medicine,  vol.  i.  p.  913. 


THE   TEETH  AND    THEIR  DISEASES.  187 

Trismus. — This  term  has  its  application  alone  to  the  anchylosis 
of  the  temporo-raaxillary  articulation  ;  it  expresses  the  simple  lock- 
ing or  fixing  of  the  jaws.  As  there  are  many  causes  or  conditions 
involved  in  such  locking,  so,  of  course,  we  have  conjoined  terms 
expressive  of  such  different  lesions :  trismus  traumaticus,  including 
tetanus, — the  locked  jaw  from  wounds  and  other  local  external  inju- 
ries; trismus  dentium,  arising  from  associative  dental  lesions;  tris- 
mus nascentium,  or  trismus  neonatorum,  —  infantile  tetanus.  In 
strictness  of  application,  the  term  trismus,  however,  applies  only  to 
gnashing,  spasmodic,  or  nervous  lockjaw,  and  is  without  true  expres- 
sion or  meaning  when  applied  to  other  forms.  It  might  be  best 
viewed  as  referring  to  the  medical  rather  than  to  the  surgical  aspect 
of  the  lesion. 

Tetanus — from  tsivw,  to  stretch — is  a  disorder  of  the  nervous 
system,  presenting  its  manifestations  in  spasms,  and  affecting  in 
nearly  every  instance  the  muscles  of  mastication,  thus  producing 
gnashing,  or,  it  may  be,  locking  of  the  jaws.  Tetanus  is  decidedly 
a  nervous  disease  in  its  expressions,  and  is  primarily  confined  to 
the  true  spinal  system,  being  produced  in  some  individuals  by  the 
most  trifling  injuries,  many  cases  being  on  record  where  the  simple 
extraction  of  a  tooth  has  sufficed  to  provoke  it.  The  terms  opisthot- 
onos, emprosthotonos,  and  pleurosthotonos  are  employed,  together 
with  trismus,  to  designate  the  groups  of  muscles  implicated  in  the 
derangement. 

Tetanus  is  divided  into  traumatic  and  idiopathic,  and  into  acute 
and  chronic;  the  first  following  wounds  and  other  injuries,  the 
second  arising  without  assignable  cause.  The  first  form  is  usually 
acute  in  character;  the  latter  is  apt  to  be  chronic,  and,  to  the  extent 
of  its  chronicity,  amenable  and  responsive  to  treatment. 

As  predisposing  causes  of  tetanus,  the  experience  and  observations 
of  Baron  Larrey  would  seem  to  give  cold  and  dampness  prominent 
positions.  Dr.  Kane,  in  his  Arctic  Explorations,  alludes  to  the  death 
of  two  of  his  men  from  tetanic  spasms,  after  being  exposed  to  intense 
cold.  Extreme  heat  is  certainly  another  of  such  predisposing  causes, 
tetanus  being  as  common  in  the  very  hot  as  in  cold  temperatures, 
both  extremes  acting,  most  likely,  by  provoking  centric  nervous  irri- 
tation. 

Symptoms. — Tetanus,  although  sometimes  coming  on  suddenly, 
has  more  commonly  a  premonitional  history.  Instances  are  recorded 
where  the  spasms  have  arisen  almost  simultaneously  with  the  recep- 
tion of  a  wound.     Such  cases  are,  however,  exceedingly  rare,  and 


188  ORAL  DISEASES  AND   SURGERY. 

indicate  a  predisposition  whicli  renders  the  disease  almost  neces- 
sarily fatal.  On  the  other  hand,  it  is  exceedingly  common  to  find 
the  condition  remaining  in  abeyance  until  the  external  wound  has 
completely  healed.  A  case  of  this  latter  character  came  only  a 
short  time  back  under  my  own  immediate  observation,  where  a  lady, 
while  searching  in  a  barn  for  eggs,  accidentally  ran  a  rusty  nail 
into  her  knee,  not,  however,  penetrating  the  articulation.  Four  days 
after  the  reception  of  the  injury,  with  the  break  fairly  healed,  eni- 
prosthotonos  supervened  ;  yet  the  spasms  quickly  disappeared  upon 
the  opening  of  the  wound  with  a  bistoury  and  the  introduction  of  a 
delicate  tent,  thus  compelling  a  filling  up  of  the  parts  from  the  bottom. 
The  irritation  of  a  nerve  radicle  by  its  being  caught  and  compressed 
in  a  cicatrix  is  a  reasonable  explanation  of  neuralgia  and  tetanus 
supervening  on  the  liealing  of  a  punctured  or  lacerated  wound,  and 
seems  to  have  had  an  example  in  this  case. 

Commonly,  tetanus  exhibits  its  approach,  as  suggested,  in  a 
gradual  manner.  Attention  is  first  directed  to  a  sense  of  general 
malaise ;  then  supervenes  stiifness  of  the  movements  of  the  lower 
jaw,  as  though  the  muscles  were  exhausted.  This  stiffness,  in- 
creasing to  soreness,  extends  to  the  muscles  of  the  neck.  The 
mouth  becomes  dry  and  sore ;  mastication  grows  painful,  and 
swallowing  difficult,  a  sense  of  spasm  and  suffocation  resulting 
when  these  offices  are  attempted.  Eventually  the  masseters,  tem- 
porals, and  pterygoid  muscles  become  stiffened  and  bulging;  the 
orbicularis  puckered  and  contracted  ;  the  eyelids  are  closely  approxi- 
mated; the  zygomatici  are  liable  to  become  fixed,  thus  giving  a 
peculiar  expression  known  as  the  Risus  Sardonicus.  Following 
these  symptoms,  almost  any  of  the  voluntary  muscles  may  become 
implicated,  the  abdominal  group,  particularly  the  recti,  corrugating 
and  knotting  themselves.  Colicky  symptoms  soon  supervene,  in- 
duced by  spasms  of  the  muscular  coat  of  the  bowels;  or  difficulty 
in  respiration  may  arise,  from  spasms  of  the  diaphragm.  Opis- 
thotonos, emprosthotonos,  pleurosthotonos,  or,  it  may  be,  a  most  un- 
yielding trismus  now  develops,  according  as  the  force  of  the  irritant 
may  select  special  groups  of  the  muscular  system  upon  which  to 
expend  itself.  That  tetanus  does  not  implicate  the  ganglia  of 
special  sense,  but  is  confined  to  the  spinal  cord,  medulla  oblongata, 
and  cerebellum,  is  demonstrated  in  a  clearness  of  the  intellect  which 
continues  during  the  attack. 

The  bowels,  in  tetanus,  are  commonly  found  obstinately  consti- 
pated, depending  on  the   general  derangement  of  the   alimentary 


THE   TEETH  AND    THEIR  DISEASES.  189 

canal;  and  motion,  when  it  does  obtain,  is  accompanied  with  fetor 
of  a  most  offensive  character  and  great  persistence.  The  bladder 
may  be  closed  by  spasm  of  the  muscular  fibres  of  its  neck,  or  these 
may  be  so  relaxed  that  complete  incontinence  exists.  The  tongue, 
when  involved,  tends  to  be  thrust  forward,  and  is  thus  often  lacer- 
ated in  the  spasmodic  occlusions  of  the  teeth. 

Acute  tetanus  seldom  has  a  greater  duration  than  four  days,  the 
patient  perishing  either  from  asphyxia  in  a  spasm,  or  otherwise  from 
exhaustion.  Chronic  tetanus,  on  the  contrary,  runs  on  day  after  day, 
most  frequently  eventuating  favorably.  One  is  impressed  with  the 
sense  of  a  battle,  in  which  nature  properly  supported  may  reasonably 
be  expected  to  win. 

Pathology. — Because  of  the  absence  of  definite  pathological  lesions, 
more  or  less  diversity  of  opinion  exists  concerning  the  conditions  of 
this  disease.  Sporadic  or  traumatic  cases,  where  tetanus  has  shortly 
supervened  upon  injury  to  a  nerve,  naturally  direct  attention  in  such 
direction.  Investigations  into  nerve-relations,  however,  prove  so 
unsatisfactory  that  there  seems  now  quite  a  tendency  to  revive  the 
humoral  origin,  a  view  maintained  with  all  earnestness  by  Rose, 
and  favored  by  both  Billroth  and  Dr.  Richardson,  the  latter  sug- 
gesting that  it  may  eventually  prove  to  be  the  result  of  the  absorption 
of  some  septic  material.  "  In  this  disease,"  says  this  author,  "the 
poison,  in  my  opinion,  is  first  developed  in  the  wound  as  the  result 
of  decomposition.  Thence  carried  into  the  circulation,  the  new 
substance,  without  any  necessary  increase  of  its  own  parts,  excites 
a  zymosis,  ending  in  the  production  of  an  alkaloidal  or  alkaline  body, 
which  has  all  the  power  of  exciting  the  symptoms  of  spasm  as  much 
as  strychnine  itself."  Billroth  inclines  to  ally  the  condition  with 
tlifi  infectious,  phlogistic.  "  It  is  known,"  he  says,  "  that,  by  blood- 
poisoning  with  strychnia,  severe  spasms,  and  with  alcohol,  psychical 
disturbances  (drunkenness),  may  be  induced  ;  hence  it  is  very  possi- 
ble that  this  disease  may  result  from  poisoning  with  a  peculiar  sub- 
stance, only  very  rarely  formed  in  wounds,  and  thence  absorbed." 

The  .symptoms  of  tetanus  indicate  irritation  of  the  spinal  medulla. 
Rokitansky  describes,  from  autopsies  made  by  him,  evidences  of  vas- 
cular relations  of  this  substance  as  exhibited  in  the  development  of 
young  connective  cells.  Other  observers,  however,  have  failed  to 
find  these  expressions. 

The  reviewer  of  the  article  Tetanus  in  Reynolds's  "  System  of 
Medicine"  (see  Britiah  and  Foreign   Medico- Ghirurgical  Bevieiv, 


190  ORAL  DISEASES  AND  SURGERY. 

vol.  xiii.)  says,  "  The  author  does  not  attempt  to  trace  any  connec- 
tion between  the  acknowledged  causes,  cold  and  damp  and  wounds, 
and  the  production  of  such  a  fearful  consequence  in  only  a  few  cases. 
With  regard  to  its  relation  to  hydrophobia  and  analogy  of  the 
latter  to  that  of  snake-bites,  may  not  the  connecting  link  between 
chilled  wounds  and  spasmodic  paroxysms  be  an  animal  poison  gen- 
erated in  the  wound  during  the  process  of  healing?  and  being  an 
animal  poison,  therefore  poisonous  in  extremely  minute  doses  ?  and 
being  an  animal  poison,  therefore  latent  in  the  system  for  long 
periods  ?  and  being  an  animal  poison,  therefore  specially  fatal  to  the 
nervous  sj^stem  ?  The  greater  tendency  in  punctured  and  closed 
wounds  to  cause  tetanus  is  very  suggestive  of  the  needle-like  ser- 
pent's fang,  and  the  frequent  triviality  of  the  dog's  bite,  which  are 
more  deadly  the  less  blood  flows." 

Holmes  (in  his  chapter  on  Tetanus ;  see  vol.  i.  p.  330),  after  a  review 
of  the  morbid  anatomy,  as  referred  to  by  various  observers,  remarks 
the  obscurity  in  which  the  pathology  is  involved.  "Some,"  he 
says,  "  are  seen  to  affirm  tetanus  to  be  an  irritation  of  a  peculiar 
kind,  affecting  the  excito-raotory  apparatus ;  that  the  irritating  cause 
may  be  excentric  at  the  extremity  of,  or  in  the  course  of,  the  afferent 
spinal  nerve,  or  it  may  be  centric  within  the  spinal  canal  itself. 
Some  consider  it  to  be  an  exaltation  of  the  polarity  of  the  cord  and 
medulla.  Others,  again,  maintain  it  to  be  identical  with  inflamma- 
tion of  the  spinal  cord  and  medulla  oblongata,  and  adduce  cases  of 
inflammation  of  such  structures  as  inducing  symptoms  of  tetanus." 

Principles  of  Treatment. — "  If  the  difficulty  of  ascertaining  patho- 
logical conditions,  upon  which  all  rational  indications  of  cure  should 
be  based,"  says  Dr.  Copland,  "  be  so  great  in  this  malady  as  not  to 
have  hitherto  been  overcome,  can  it  be  a  matter  of  surprise  that  the 
means  which  have  been  resorted  to,  both  by  physicians  and  sur- 
geons, in  its  treatment,  have  been  most  opposite  in  their  effects,  the 
most  different  in  their  nature,  and  in  every  respect  most  empirical 
and  uncertain  ?  •  In  this  state  of  our  knowledge,  it  would  be  better 
to  leave  nature  to  her  unaided  efforts,  to  observe  closely  and  accu- 
rately what  is  the  true  procession  of  changes  and  of  their  manifesta- 
tions, and  to  ascertain  the  seats  and  the  extent  of  lesion  as  soon 
after  death  as  may  be  attempted  with  propriety." 

The  treatment  that  has  most  commonly  suggested  itself  seems  to 
be  that  of  anaesthesia,  opium  and  chloroform  being  much  depended 
on.    Of  the  former  medicine  as  many  as  twenty  or  more  grains  have 


« 


THE    TEETH  AND    THEIR  DISEASES.  191 

been  used  in  the  course  of  a  day,  or  a  correspondence  in  the  subcu- 
taneous use  of  morphia.  The  greatest  gain  in  treatment  seems  to 
be  to  prolong  the  disease  into  chronicity,  thus  wearing  out,  as  it 
were,  the  force  of  the  active  cause.  Bilh'oth  refers  to  the  use  of 
warm  potash  baths,  and  the  application  of  strong  irritants  along  the 
spine,  large  blisters,  moxse,  but  does  not  feel  that  experience  tends 
to  indorse  any  of  them.  On  the  contrary,  referring  more  particu- 
larly to  the  chronic  cases,  he  suggests  that  the  patient  be  allowed  to 
remain  as  quiet  as  possible,  guarded  against  all  injurious  influences, 
especially  from  physical  or  mental  excitement,  the  general  aim  of 
the  treatment,  he  thinks,  being  to  alleviate  the  acute  course  and 
make  it  more  chronic,  as  this  gives  more  hope  of  recovery. 

Of  the  internal  remedies  that  have  been  employed,  almost  every 
class  and  description  have  been  tried,  without,  as  yet,  any  result  in 
the  way  of  a  specific  or  an  approach  in  such  direction.  "  Altera- 
tives, in  the  shape  of  the  varied  preparations  of  mercury,  large  doses 
of  fixed  alkalies,  solutions  of  arsenic,  etc. ;  diure'tics,  in  the  form  of 
tincture  of  cantharides,  oil  of  turpentine,  given  in  frequent  and  large 
doses  so  as  to  irritate  the  urinary  passages  or  to  occasion  bloody 
urine  ;  sedatives,  such  as  digitalis,  tobacco,  nicotina,  hydrocyanic 
acid,  aconitina;  anodynes  and  narcotics,  as  opium,  morphia,  bella- 
donna, colchicum,  cannabis  indica,  ether  and  chloroform  internally 
and  by  inhalation  ;  stimulants  and  antispasmodics,  including  musk, 
ammoniacum,  camphor,  turpentine,  assafetida,  castor,  wine,  and 
other  stimulants ;  tonics,  such  as  quinine,  bark,  strychnia,  iron, 
zinc,  etc. ;  hygienics  and  dietetics,  as  support,  milk-diet,  etc. ;  injec- 
tions into  the  veins  of  solutions  of  opium,  stramonium,  etc. ;  tra- 
cheotomy and  laryngotomy.  The  calabar  bean  in  sufficient  doses  to 
paralyze  the  voluntary  muscles  has  been  affirmed  to  be  attended  with 
marked  success,  although  it  has,  on  the  other  hand,  failed  very  fre- 
quently."  (Alfred  Poland,  Holmes's  "System  of  Surgery.") 

The  treatment  of  tetanus  by  woorara  has  of  late  excited  some 
attention,  mainly  through  the  work  of  Mr.  Morgan.  According  to 
Demme,  this  most  powerful  poison  has  out  of  twenty  cases  resulted 
in  eight  cures.  It  is  recommended  by  Spencer  Wells,  Broca,  Chas- 
saignac,  and  others  ;  the  dose  is  given  as  from  one-eighth  to  one-half 
grain  to  an  adult.  To  one  not  familiar  with  the  action  of  woorara,  it 
would  seem  necessary  to  recommend  great  caution  in  its  employ- 
ment. Most  interesting  experiments  have  been  performed  with 
woorara  upon  the  lower  animals,  particularly  a  series  in  1858  by 
Dr.  J.  J.  Woodward. 


192  ORAL   DISEASES  AND   SURGERY. 

The  use  of  the  calabar  bean  has  come  to  be  much  relied  on  in  the 
United  States.  Eighteen  cases  are  reported  by  Dr.  Eben  Watson 
in  which  this  medicine  was  used,  yielding  ten  recoveries.  The  dose 
varies  with  the  effect  produced  in  controlling  the  spasms.  The  action 
seems  to  be  that  of  a  direct  sedative  to  the  spinal  cord,  patients, 
while  under  its  influence,  commonly  taking  food  with  ease.  One 
grain  may  be  commenced  with  as  a  dose,  increasing  the  quantity 
2?ro  re  nata. 

The  new  preparations  hydrate  of  chloral  and  croton-chloral  have 
in  them  considerable  promise  in  this  direction.  A  peculiar  action 
from  this  latter  agent  is  found,  that  at  first  a  high  degree  of  anaes- 
thesia in  the  head  is  produced,  while  sensibility  in  other  parts  of  the 
body  remains  intact.  The  second  stage  is,  that  the  spinal  cord 
loses  its  function,  and  reflex  excitability  is  everywhere  extin- 
gui.shed.  During  this  stage,  i)ulse  and  respiration  remain  unchanged. 
Tiie  third  stage,  which  is  induced  by  large  doses,  is  characterized 
by  paralysis  of  the  medulla  oblongata,  and  death.  Animals  may, 
however,  be  kept  alive  by  artificial  respiration,  because  the  function 
of  the  heart  is  not  interfered  with  ;  while  the  ultimate  effect  of 
hydrate  of  choral  is  to  paralyze  the  heart. 

The  local  treatment  which  has  been  had  recourse  to  in  tetanus 
consists  in  laying  open  wounds,  their  thorough  cleansing,  and  the 
application  of  antiseptics;  division  of  nerves,  the  application  of 
counter-irritants,  the  employment  of  sedatives,  ice-bags  to  the  spine, 
cold  and  warm  shower-baths,  electricity,  attention  to  inflamed  and 
suppurating  wounds,  etc. 

Trismus  Nascentium. — Lockjaio  in  new-horn  children. — The  fre- 
quency of  this  condition,  and  its  fatality  to  a  particular  order  of 
infantile  life,  make  its  study  one  of  interest  and  importance  to  the 
practitioner.  It  is  decidedly  a  disease  associated  with  the  period 
of  the  desiccation  and  phenomenal  change  occurring  with  the  coi'd 
and  umbilicus,  and  is  found  confined,  therefore,  to  the  time  associ- 
ated with  these  changes, — never  occurring  before  the  second  day 
after  birth,  and  seldom  after  the  fourteenth. 

Tetanus,  of  which  this  is  a  form,  has  its  expression  and  association 
exclusively  with  the  nervous  system  of  organic  life, — the  excito- 
motor.  That  trismus  nascentium  is  therefore  a  special  disease,  is 
not  to  be  entertained  for  a  single  moment ;  it  is  simply  tetanus 
occurring  from  generally  evident  causes  in  the  newly-born,  and  is  to 
have  the  consideration  and  treatment  of  the  disease  as  found  any- 
where else.     Wherever  the  nervous  system  of  organic  life  exists  in 


THE   TEETH  AND    THEIR   DISEASES.  193 

exquisite  deve]opment,  and  wherever  it  is  excited  from  any  cause  to 
excess  of  expression  or  action,  there  is  found  the  danger  of  trismus. 
Hence  in  infants  of  the  negro  race,  and  particularly  those  born 
of  parents  of  less  than  average  intelligence  and  resident  in  hot  cli- 
mates, the  condition  is  found  most  widely  to  prevail.  In  the  southern 
section  of  the  United  States,  and  in  the  West  Indies,  the  mortality 
of  infantile  deaths  from  this  single  cause  is  estimated  by  some 
observers  at  not  less  than  twenty-five  per  cent. ;  while  it  is  affirmed 
that  in  the  equatorial  regions  of  South  America  in  some  years 
more  than  half  the  infants  born  fall  victims  of  this  disease.  In  an 
epidemic  form  in  which  it  is  found  occasionally  to  prevail,  the  mor- 
tality of  certain  neighborhoods  has  amounted  to  four-fifths  of  the 
births. 

That  trismus  nascentium  is  not  confined,  however,  to  the  hot  lati- 
tudes is  to  be  inferred,  not  only  from  the  report  of  many  cases  else- 
where, but  from  its  oneness  with  tetanus  proper.  According  to 
Dr.  Holland,  it  is  very  prevalent  on  the  southern  coast  of  Iceland, 
also  at  St.  Kilda,  one  of  the  western  islands  of  the  Scottish  coast. 
In  Elbing,  .Prussia,  cases  are  announced  as  occurring  frequently, 
thirty-seven  being  recorded  from  I8G3  to  1865  in  a  population  of 
twenty-seven  hundred.  In  Dublin,  the  disease  has  prevailed  so 
alarmingly  that  at  one  time,  for  a  limited  period,  nineteen-twentieths 
of  the  infantile  deaths  occurring  in  the  Lying-in  Hospital  of  that  city 
were  from  this  cause,  the  death-rate  being  one  to  every  sixth  child 
born.  Being  attributed  to  ill  ventilation  and  the  absence  of  proper 
hygienic  requirements,  attention  was  at  once  directed  to  these  pro- 
phylactics, with  the  result  of  decreasing  the  rate  to  one  in  nineteen. 

Symptoms. — Like  the  manifestations  of  the  disease  as  exhibited  in 
the  adult,  the  prodromous  period  may  be  deficient  in  signs  sufficiently 
marked  to  attract  ordinary  observation.  The  child  may  seem  rest- 
less and  more  excitable  than  usual,  but  this  is  apt  to  be  attributed 
to  any  other  than  the  true  cause.  A  few  hours,  or  it  may  be  days, 
jn  intervene,  when  the  infant,  apparently  anxious  for  the  nipple,  is 
found  unable  to  take  hold  of  it.  This,  together  with  an  occasional 
^mothered  cry,  as  if  the  child  was  in  distress,  first  brings  it  under 
Fthe  notice  of  the  physician. 

If  now  the  jaws  be  examined,  more  or  less  rigidity  will  be  found 
to  exist,  the  masseter  muscles  seeming  the  ones  principally  aifected. 

Y  From   these  the  expression  n)ay  extend  to  any  others,  and  does 

Y  80  in  a  very  few  hours ;  or  it  may  be  that  the  first  manifestation  of 
|ki  muscular  involvement  is  exhibited  in  spasm,  the  jaw  being  shut  with 

13 


194  ORAL  DISEASES  AND   SURGERY. 

a  snap  which  has,  in  instances,  partially  amputated  the  tongue  ;  or 
the  spasm  may  affect  some  muscle  of  the  limbs  or  trunk.  Such 
commencement  of  the  active  stage  of  the  disease  is,  however, 
infrequent. 

In  the  fully-developed  stage  of  infantile  trismus  the  spasms  are 
found  quite  frequent.  The  agitation  of  the  child  is  very  great.  The 
smothered  scream  which  it  emits  is  peculiarly  painful, — itself  spas- 
modic in  character  from  affection  of  the  respiratory  muscles.  The 
little  sufferer  foams  at  the  mouth  ;  the  fists  are  tightly  clinched;  the 
feet  are  flexed  upon  the  ankles,  with  the  great  toe  abducted  ;  the 
head  is  drawn  back  by  the  cervical  muscles  ;  the  surface  grows  livid, 
the  infant  dying  in  the  paroxysm,  or,  otherwise,  either  receiving 
respite  in  which  relaxation  ensues,  or  sinking  into  death  through 
coma.  The  duration  of  the  disease  is  commonly  about  two  days; 
but  cases  are  recorded  where  death  has  not  occurred  until  the  third 
week  of  the  attack. 

Causes. — First,  there  may  be  assumed  to  be  a  predisposition 
(though  this  need  not  of  necessity  exist),  such  predisposition  being 
impressed  on  the  child  in  utero  by  the  hot  and  foul  air  and  common 
filthiness  of  habit  which,  from  its  inception,  have  attended  it  iq  the 
person  of  the  parent  who  has  borne  it:  this  finding  proof  in'the  fact 
that  as  the  condition  of  parents  has  been  improved,  so  has  trismus 
diminished,  the  disease  finding  its  habitat  almost  exclusively  amidst 
the  squalor  and  poverty  of  the  lowest  and  least  intelligent  classes. 
Other  predisposing  causes  are  found  in  any  and  all  relations  of  de- 
pressing character.  Thus,  hot  moist  days,  followed  by  cold  nights, 
have  been  sufficiently  recognized  to  be  among  the  most  efficient  of 
the  predisposing  cajases,  the  explanation  being  found  in  the  inter- 
ruption of  the  functions  of  the  skin.  Miasma,  no  doubt,  contributes 
its  quota  through  its  depressing  action  on  the  nervous  system, — 
tetanus  being  associated  with  the  period  of  reaction. 

In  papers  published  in  1846  and  1818,  Dr.  J.  Marion  Sims  ad- 
vanced the  view  that  the  cause  of  trismus  nascentium  lay  in  a 
pressure  exerted  on  the  medulla  oblongata  and  the  nerves  originating 
from  it,  produced  by  displacement  of  the  cranial  bones,  and  espe- 
cially the  occipital,  such  displacement  occurring  in  the  parturitive 
effort,  and  capable  of  being  corrected ;  but  that  the  cases  observed 
by  him  w^ere  exceptional,  and  not  common,  seems  clear  enough  by 
the  universal  denial  of  his  premises,  following  observations  elicited 
by  the  publication  of  his  views. 

Whatever,  then,  maybe  a  predisposing  cause  of  infantile  trismus. 


THE    TEETH  AND    THEIR   DISEASES.  195 

the  chief  exciting-  one  is  found  in  association  with  the  umbilical  cord: 
and  first  this  associates  with  the  tying  and  excision  of  it.  A  cord 
cut  with  a  dull  blade  may  be  thus  put  into  a  condition  of  irritability, 
Avhich,  reacting  upon  a  highly  predisposed  system,  might  bring 
on  an  immediate  attack  of  spasm.  An  ill-strangulated  cord  may 
be  classed  as  the  second  of  the  offending  causes.  A  common  habit 
with  midwives  among  the  poorer  classes  is  to  wrap  the  parts  with 
packthread.  This  is  not  only  an  inadequate  protection  against 
hemorrhage,  as  in  my  experience  I  have  several  times  had  occasion 
to  witness,  but  it  is  irritating  to  the  parts  even  in  the  remote  aspect 
of  its  relation  with  the  general  system,  and  may  readily  arouse  the 
abeyant  irritability. 

The  umbilical  cord  separates  from  the  body,  physiologically 
speaking,  as  does  the  stem  from  the  ripe  fruit.  When  such  is  not  the 
character  of  the  disjunction,  the  conditions  are  to  be  expressed  as 
pathological,  being  associated  with  more  or  less  inflammation,  ulcer- 
ation, and  local  irritation.  The  ordinary  period  required  for  the 
separation  of  a  funis  is  from  three  to  six  days.  During  this  period 
the  parts  should  be  kept  enveloped  in  a  fold  of  old  half-worn  linen, 
prepared  as  a  dressing  by  snipping  a  piece  out  of  the  centre  after 
the  manner  of  the  Maltese  cross  ;  the  cord  to  be  passed  through  this 
hole,  and  thus,  by  its  envelopment,  separated  from  contact  with  the 
person  of  the  child.  In  hot  climates,  such  dressing,  combined  with 
oil,  or  antiseptics,  is  the  more  necessary,  as  the  danger  is  to  be 
guarded  against  of  having  the  parts  serve  as  a  habitat  for  the 
deposit  of  larvae, — a  not  infrequent  cause  in  itself  of  tetanus. 

Treatment. — From  the  constitutional  standpoint,  nothing  more 
may  be  done  than  is  to  be  inferred  from  the-  directions  given  in 
general  tetanus.  Anodynes,  antispasmodics,  anaesthetics,  and  altera- 
tives, these  we  may  try  ad  libitum,  but  the  result  will  amount  to 
very  little  if  any  unappreciated  or  unremoved  cause  exists  in  the 
way  of  local  irritation.  Attention  is  therefore  to  have  a  first  direc- 
tion to  the  umbilical  region,  and  such  attention,  if  directed  in  the 
incipient  stage,  may  not  unfrequently  result  in  aborting  the  attack. 
If  an  ill-incised  cord  be  found,  make  at  once  a  fresh  and  clean  cut 
nearer  the  body.  If  the  cord  is  indififerently  strangulated,  remove 
at  once  the  ligature,  and  replace  with  a  well-waxed  silk  thread,  or 
otherwise  place  a  new  ligature  nearer  the  body.  If  separation  of 
the  funis  is  not  progressing  with  its  usual  physiological  harmony, 
then  treatment  will  be  needed  as  indicated.  Cleanliness  is  to  be 
strictly  enjoined,  and  vascular  action  is  to  be  stimulated  or  depressed, 


196  ORAL  DISEASES  AND  SURGERY. 

as  required, — not  as  indicated  by  tbe  pulse,  for  this  in  tetanus  affords 
very  little  guidance,  but,  as  implied,  at  the  seat  of  local  offense. 
Among  negroes,  as  remarked  by  Dr.  James  S.  Baily,  vvliose  oppor- 
tunities for  observation  seem  to  have  been  extensive,  "the  unclean- 
liness  and  unsuitableness  of  the  umbilical  dressings  are  by  far  the 
most  common  of  the  exciting  causes  of  the  disease.  Among  these 
people  infants  are  found  not  only  fetid  with  the  ammoniacal  smell 
of  the  urine  with  which  they  are  wet  from  morning  until  night,  but 
are  loaded  with  fecal  matter,  so  thoroughly  saturating  the  appendage 
of  the  funis  as  to  render  its  drying  impossible.  In  consequence  of  tbe 
sphacelated  condition  of  the  cord,  it  gives  off  the  material  of  death 
and  decay,  which,  being  deposited  in  direct  contact  with  the  active 
absorbents,  must  necessaril}^  act  as  a  fearful  causation."  This  gen- 
tleman, who,  during  a  residence  in  Texas,  was  able  to  collect  and 
make  notes  of  two  hundred  cases,  tells  us  that  in  his  experience  he 
has  never  observed  a  case  of  lock-jaw  when  due  regard  was  paid  to 
proper  instructions  in  reference  to  the  management  and  dressing  of 
the  umbilicus.  Tumefaction  and  redness  without  suppuration  are 
always,  he  thinks,  expressions  to  excite  apprehension,  and  are  to 

receive  immediate  attention.     Quoting  a  Mrs.  0 ,  a  lady  living 

on  the  Brazos,  in  Texas,  observation  is  directed  to  the  value  of  a 
mush  poultice  applied  to  the  navel  immediately  after  birth,  to  be 
continued  until  the  falling  off  of  the  cord,  or  while  any  signs  of  in- 
flammation exist,  the  lady  asserting  that  with  such  practice  employed 
with  her  own  servants  they  have  never  lost  a  case.  This,  however, 
evidently  applies  to  the  use  of  the  poultice  as  a  prophylactic,  —  a 
direction,  indeed,  in  which  the  physician  finds  himself  most  useful. 

TRISMUS   DENTIUM. 

In  the  chapter  on  Dental  Anomalies  we  studied  the  process  of 
maxillary  enlargement,  and  understood  how  that  process  was,  in 
part,  counterbalanced  by  an  untimely  extraction  of  the  deciduous 
teeth.  It  was  further  shown  how  certain  derangements  of  the 
dental  organs  were  a  common,  if  not  a  necessary,  sequence  to  such 
abridgment  of  the  arch  ;  and,  among  other  ill  effects,  reference  was 
made  to  the  impossibility  of  a  natural  and  healthy  evolution  of  the 
wisdom  teeth,  and  to  conditions  favoring  periodonteal  inflamma- 
tion. In  this  section  we  are  to  consider  lock-jaw  as  it  has  a  signifi- 
cation exclusively  surgico-dental. 

Such  dental  signification,  however,  will,  I  apprehend,  outside  of 


THE   TEETH  AND    THEIR   AIS EASES.  197 

tetanic  conditions  proper,  be  recognized  to  have  the  widest  relation- 
ship to  the  lesion,  and,  indeed,  if  my  experience  has  not  been  un- 
commonly one-sided,  it  will  be  found  to  have  the  very  closest  rela- 
tionship; for  I  incline  to  think  that,  in  every  twenty  cases  of  local 
trismus,  eighteen  have,  as  the  primary  lesion,  periodontitis,  in  some 
of  its  varied  forms. 

We  have  considered  the  retraction  of  the  dental  arch.  "We  will 
now  look  at  such  lesions  as  this  retraction  has  engendered — lesions 
pertaining  to  the  subject  under  consideration. 

The  troubles  of  an  individual  afflicted  with  a  contracted  dental 
arch  are  most  apt  to  begin  at  about  the  fifteenth  or  sixteenth  year  of 
age.  If  you  look  into  such  a  mouth  you  will  find  the  teeth  crowded 
together  in  most  uncomfortable-looking  positions.  The  last  molar 
of  the  lower  jaw  you  will  see,  quite  likely,  jammed  into  the  ramus; 
while  the  same  tooth  of  the  superior  jaw  will  be  found  occupying 
the  very  extreme  of  the  tuberosity  of  the  bone. 

At  this  period,  unless,  fortunately,  the  teeth  are  possessed  of  un- 
common resistance,  you  will  find  them  breaking  down  from  approx- 
imal  caries;  while,  as  the  result  of  such  caries,  combined  with  the 
crowded  condition  of  the  fangs,  the  alveolo-dental  periostea  enter 
into  a  subinflammatory  state,  and  become  as  ready  to  take  on  acute 
disease  as  is  tinder  to  respond  to  a  spark. 

If,  then,  interference  with  the  elongatory  process  has  been  such 
as  to  yield  these  troubles  when  only  twenty-eight  teeth  have 
erupted,  it  is  plain  to  infer  that  the  development  of  the  four  dentes 
sapientiae  must  proportionally  add  to  the  difficulties.  And  only 
by  appreciating  the  character  of  such  trouble  can  we  fit  ourselves  to 
abort  its  lesions. 

These  lesions  are  periodontitis,  alveolar  abscess,  stomatitis,  ostitis, 
necrosis,  trismus,  etc. 

In  the  chapter  on  Anomalies,  it  was  remarked  that  all  dental  trou- 
bles arising  from  retraction  and  diminution  of  the  maxillary  arch 
could  be  guarded  against  by  a  timely  extraction  of  certain  of  the 
permanent  teeth  ;  and  from  this  we  might  infer  that  troubles  arising 
from  an  advancing  wisdom  tooth  might  also  be  provided  for  on  the 
same  principle,  namely,  by  extracting  the  second  molar,  thus  se- 
curing the  required  alveolus. 

These  pathological  conditions,  and  the  remedial  and  prophylactic 
indications  so  plainly  written  over  them,  it  would  seem  impossible, 
because  of  their  very  simplicity,  to  overlook  ;  that  they  are  over- 


/ 


198  ORAL  3  IS  EASES  AND  SURGERY. 

looked,  however,  is  too  evident,  from  their  many  secondary  lesions 
which  the  surgeon  finds  himself  constantly  called  on  to  treat. 

The  view  was  advanced  that  the  majority  of  the  cases  of  trismus 
would  be  found  to  have,  as  the  primary  lesion,  some  periodonteal 
trouble.  Of  course  I  would  be  understood  as  not  including  trismus 
neonatorum,  or  any  trismus  traumaticus,  the  lesion  of  which  was 
self-evident.  A  child  might  get  a  severe  burn  on  the  cheek,  and 
trismus  be  a  result  of  the  innodular  tissue,  which  would  close  up 
the  break  in  the  continuity.  Anchylosis  might  exist,  the  sequence 
to  articular  disease,  as  we  have  studied.  Traumatic  tetanus  affect- 
ing the  muscles  of  the  jaw  has,  as  we  know,  a  primary  lesion  com- 
bined with  peculiar  nervous  disturbances,  which  would  give  the 
diagnosis.  But  it  is  to  the  numberless  cases  of  so-called  idiopathic 
trismus  I  allude,  and  to  the  cases  of  trismus  which  have  evidently 
a  local  signification  alone  ;  that  signification  not  being  always  very 
evident,  or  otherwise  associated  with  so  many  complications  as  not 
to  be  readily  distinguishable. 

Reports  of  case  after  case  of  unappreciated  local  trismus  come  to 
our  attention, — of  the  lesion  being  referred  to  this  cause  and  the 
other  cause, — the  treatments  being  as  various  as  the  diagnoses. 
Many  of  the  inferences  thus  presented  are,  without  doubt,  just  and 
reliable  ;  but  I  would  give  it  as  a  reliable  experience  that  where, 
personally,  I  have  had  the  opportunity  of  seeing  such  cases  as  would 
seem  to  be  their  parallel,  I  have  mostly  been  able  to  point  out  to  the 
practitioner  exhibiting  the  case,  as  the  primary  lesion,  some  dental 
disturbance,  simple  or  obscure. 

In  the  epitome  of  Braithwaite,  vol.  ii.  page  191,  is  a  case,  the 
diagnosis  and  treatment  of  which  will  serve  as  an  example.  Dr., 
Sellers,  the  practitioner  who  reports  it,  ascribes  the  trismus  to  a 
complication  of  inflammatory  and  nervous  derangements.  Now, 
while  I  might  have  found  myself  wrong,  yet  from  the  history,  and 
from  the  age  of  his  patient,  I  chould  have  expected,  had  I  seen  the 
case  with  him,  to  be  able  to  point  out  that  an  ulcerated  sore  throat, 
to  which  he  alludes,  had  its  primary  lesion  in  a  periosteal  trouble 
of  the  alveolo-dental  membrane ;  let  the  reader,  however,  draw  his 
own  inference.  I  will  compare  with  this  case  one  from  my  own 
practice. 

Dr.  Sellers's  Case. — Acupuncture  in  Protracted  Lock-jaiv. — The 
patient,  twenty-five  years  of  age,  unmarried,  had  for  years  been  sub- 
ject to  attacks  of  suppurating  sore  throat,  in  which  the  jaws  often 
became  nearly  immovable  for  two  or  three'days  before  the  discharge 


4 


THE   TEETH  ASW    THEIR   DISEASES.  199 

of  matter.  Iii  1826,  she  had  a  severe  attack,  from  which  resulted 
complete  lock-jaw,  accompanied  with  hysterical  symptoms,  which 
attack  yielded,  after  six  weeks  of  treatment,  so  far  that  she  could  put 
a  teaspoon  in  her  mouth.  After  nearly  a  year,  the  jaw  again  be- 
came completely  fixed,  without  accompanying  sore  throat,  and  the 
same  treatment,  with  galvanism,  was  tried  without  efifect.  Although 
unequivocally  connected  with  hysteria,  there  was  reason  to  think, 
from  the  inflammatory  action  with  which  the  disease  set  in,  that 
the  affection  was  not  purely  spasmodic,  but  was  kept  up  by  the 
rigidity  of  the  muscles  closing  the  jaw  produced  by  inflammation ; 
in  consequence  of  which  the  antagonistic  muscles  had  become  in- 
adequate to  the  effort  of  opening  the  mouth  under  the  mere  influence 
of  volition. 

It  was  this  view  of  the  case  which  made  Dr.  Sellers  think  it 
more  reasonable,  in  making  trial  of  the  needles,  to  insert  them 
into  the  muscles  opening  the  jaw,  in  the  expectation  of  exciting 
them  to  such  a  contraction  as  might  overcome  the  rigidity  of  their 
antagonists. 

On  each  of  the  two  following  days  two  needles  were  inserted, 
one  on  each  side  of  the  mesial  line  between  the  chin  and  the  hyoid 
bone,  the  eSect  being  short,  convulsive  efforts.  The  teeth  began  to 
grate  on  each  other,  and  the  jaw  was  drawn  from  side  to  side,  not 
by  single  alternate  contractions,  but  by  severe  convulsive  move- 
ments on  one  side,  followed  by  a  nearly  equal  number  toward  the 
other  side,  interrupted  occasionally  by  a  momentary  opening  of  the 
mouth  to  the  extent  of  about  two  fingers'-breadth. 

The  convulsions  continued  after  the  needles  were  withdrawn; 
ceased  and  became  renewed  again  after  a  few  minutes,  and  returned 
spontaneously  in  the  evening  on  both  occasions.  Some  increase  of 
voluntary  power  over  the  jaw  followed  both  applications  of  the 
remedy.  After  each  trial  of  the  acupuncture  some  improvement 
was  observable  ;  but,  as  the  spontaneous  convulsion  was  almost 
always  followed  by  a  slight  loss  of  motion,  the  progress  made  was 
slow. 

The  needles  were  usually  inserted  to  the  depth  of  half  an  inch, 
and  sometimes  to  the  depth  of  an  inch. 

The  acupuncture,  together  with  leeches,  was  used  for  ten  days, 
by  which  time  the  patient  could  open  the  mouth  two  fingers'- 
breadth  and  chew  soft  substances.  She  then  went  into  the  country 
for  five  weeks,  by  which  she  derived  great  benefit;  but,  being  ex- 
posed to  cold  and  wet  on  her  return,  had  another  severe  attack,  the 


200  OBAL  DISEASES  AND   SURGERY. 

consequence  of  which  was  the  loss  of  much  of  the  voluntary  power 
over  the  muscles  of  the  jaw.  The  needles  were  again  resorted  to, 
with  the  same  effects  as  before;  but  the  pain  produced  by  the 
spasms  was  greater,  and  lasted  longer,  while  the  spontaneous 
convulsions  recurred  several  times  in  the  evenings  after  each  of  the 
first  trials.  As  leeching  did  not  succeed  in  mitigating  these  con- 
vulsions, the  temporal  artery  was  opened  with  the  desired  result, 
and  with  the  effect  at  the  same  time  of  restoring,  to  a  considerable 
extent,  the  sight  of  the  right  eye,  which  she  almost  lost  with  the 
first  attack  of  lock-jaw.  A  second  detraction  of  blood  from  the  same 
vessel  diminished  the  force  of  the  attack  so  much  as  to  permit 
the  acupuncture  to  be  used  twice  a  day.  Nine  days  after  the  re- 
newal of  the  operation,  the  jaw  had  recovered  its  natural  extent  of 
motion. 

The  aphonia,  which  had  come  on  at  the  same  time  as  the  affec- 
tion of  the  eye,  was  completely  cured  by  a  smart  shock  of  elec- 
tricity. 

The  case  referred  to  as  from  my  own  experience  occurred  in  the 
practice  of  a  friend, — my  relation  with  it  being  in  a  consultation. 
Its  history  is  as  follows: 

For  a  period  of  several  years  the  patient,  Mary  C,  twenty-four 
years  of  age,  had  been  troubled  with  attacks  of  sore  mouth  and 
throat  whenever  she  unduly  exposed  herself;  these  attacks  had 
always  associated  with  them  partial  loss  of  voice  and  general  ex- 
citation of  her  whole  nervous  system,  while  her  jaws  were  invaria- 
bly stiffened  to  a  greater  or  less  extent,  according  to  the  severity  of 
the  attack. 

On  each  of  these  occasions  she  had  depended  for  relief  upon 
domestic  treatment  or  homoeopathy.  At  the  period,  however,  of  her 
coming  under  the  care  of  my  friend.  Dr.  W.,  she  was  suffering  from 
such  severe  trouble  as  to  decide  her  usual  attendant  into  dismissing 
the  case.  Her  jaw  had  remained  so  firmly  locked  for  a  period  of  six 
weeks  that  it  was  with  difficulty  a  knife-blade  could  be  introduced 
between  the  teeth.  This  particular  spell  had  come  on  as  usual ; 
but  the  patient  said  there  was  something  about  it  which  made  her 
think  that  her  teeth  were  implicated ;  she  could  not  say  what  tooth 
or  teeth,  but  thought  it  was  one  or  more  in  the  lower  jaw. 

Now,  whatever  was  to  be  discovered  as  the  primary  lesion  in  the 
case,  its  surgical  feature,  as  it  presented  itself  to  our  attention, 
was  an  extra-capsular  mass  of  coagulated  lymph  about  the  temporo- 
maxillary  articulation,  which  overbalanced  the  influence  of  the  de- 


THE   TEETH  AND    THEIR    DISEASES.  201 

pressor  muscles,  holding'  the  parts,  of  coarse,  in  a  state  of  false 
anchylosis. 

I  asked  the  patient  if,  when  these  attacks  came  on,  her  face  had 
not  always  swelled  more  or  less.  She  said  that  it  had.  I  asked  her 
if  the  cheek  had  not  always  a  stiff,  hard  feeling  in  it,  which  wore 
away  gradually  after  such  attacks.     It  was  so,  she  told  me. 

Dr.  W.  agreeing  with  me  that  the  speediest  way  of  overcoming 
the  trismus  was  by  mechanically  breaking  up  the  adhesions,  I  pro- 
cured a  pine  stick  about  a  foot  in  length,  tapering,  wedge-shape, 
from  an  inch  and  a  half  base.  The  thinnest  portion  of  this  wedge 
was,  after  much  trouble,  passed  between  and  across  the  dental 
arches,  and,  after  being  forced  a  little  farther  on,  the  stick  was 
turned  on  its  axis,  the  adhesions  yielding  before  the  strain.  Thus 
the  mouth  w^as  opened  at  least  an  inch,  and  we  w^ere  enabled  to 
explore  this  cavity  for  the  lesion  upon  which  the  trouble  depended. 

So  far  this  case  will  be  seen  to  similate  closely  that  of  Dr.  Sellers, 
— sore  throat,  aphonia,  hysteria. 

Now,  here  we  found  'all  the  trouble  emanating  from  a  wisdom 
tooth  projecting,  as  it  were,  from  the  very  angle  of  the  jaw,  and 
half  covered  in  by  an  operculum  of  gum  drooping  over  on  it  from 
the  ramus.  The  tooth  of  course  we  at  once  removed.  The  patient 
was  then  dismissed  for  the  day,  a  sorbefacient  being  directed  for 
external  application. 

The  next  afternoon,  at  four  o'clock — no  inflammation  having  super- 
vened— we  completed,  by  our  mechanical  appliance,  the  unlocking 
of  the  jaw.  In  a  week  the  patient  was  dismissed  well.  She  has 
since  had  no  return  of  her  spells,  and  I  am  perfectly  sure  will  not 
have. 

I  think  a  parallelism  between  these  two  cases  will  be  recognized; 
but  should  the  reader  disagree  with  me,  the  study  of  them  will  not, 
I  trust,  be  without  its  profit. 

One  of  the  most  severe  cases  of  inflammation  of  the  mouth,  throat, 
and  face,  combined  with  a  bad  trismus,  1  have  ever  seen,  was  in  the 
person  of  a  medical  student  in  the  office  of  a  Dr.  C,  of  this  city — 
the  primary  lesion  being  such  a  half-erupted  wisdom  tooth  as  has 
been  alluded  to  as  being  found  in  the  preceding  case.  This  gentle- 
man, when  I  first  saw  him,  had  been  suffering  for  two  or  three 
weeks.  The  operculum  of  gum  had  been  split  up  on  two  different 
occasions.  Antiphlogisticsin  every  form  had  been  resorted  to.  The 
patient  came  to  me  under  the  anticipation  that  nothing  could  save 
him  from  necrosis  of  the  anjrle  of  the  bone. 


202  ORAL  DISEASES  AND   SURGERY. 

I  gave  this  man  one  and  a  half  pounds  of  ether ;  it  seemed  im- 
possible to  get  him  into  an  anaesthetic  condition,  his  physical  suffer- 
ing was  so  great.  Prying  his  mouth  open,  just  sufficient  to  introduce 
the  key  of  Garengeot,  I  extracted,  with  much  difficulty,  the  offending 
tooth.     In  three  days  he  was  again  attending  to  his  studies. 

This  peculiar  lesion  of  a  half-erupted  wisdom  tooth  may  well 
claim  a  moment's  attention.  Many  a  practitioner  has  been  so 
deceived  by  the  anomaly  as  to  have  been  led  widely  astray  in  the 
study  of  his  cases. 

Where  this  condition  exists,  you  will  notice,  on  looking  into  the 
mouth,  that  only  the  anterior  face  of  the  tooth  has  fairly  erupted, 
the  other  two-thirds  being  overlaid  by  the  integuments  of  the  ramus. 
You  infer  that  the  development  is  not  yet  perfected,  and  conse- 
quently it  does  not  even  occur  to  you  to  associate  disease  with  the 
parts;  but  this  tooth,  only  a  single  cusp  of  which  is  through  the 
gum,  may  have  caries  extending  into  its  pulp-cavity,  or  may  be  the 
seat  of  the  most  aggravated  periodontitis.  It  is  the  common  im- 
pression that  wisdom  teeth  decay  early ;  that  they  are  not  a  sub- 
stantial class  of  teeth.  The  fact  is  that  four-fifths  of  the  wisdom 
teeth  which  decay  so  early  have  been  destroyed  by  this  operculum 
of  gum.  The  explanation  is  very  evident.  The  decomposing  epi- 
thelial scales,  and  other  debris  of  the  mouth,  combine  in  the  acidity 
engendered  of  their  disintegration  to  irritate  the  bony  structure  of 
the  tooth,  thus  quickly  destroying  its  integrity.  I  am  sure  that  I 
have  seen  more  than  a  thousand  cases  illustrative  of  this  fact ;  and 
if  any  practitioner  will  take  the  trouble  to  dissect  off  this  fleshy  lid 
— the  proper  treatment,  by  the  way — and  examine  with  a  delicate 
probe  the  sulci  of  such  teeth,  in  nine  cases  out  of  twelve  he  will  find 
caries. 

Such  a  lesion  will  at  once  be  recognized  to  have  important  second- 
ary relations.  For  example,  I  have  myself  been  consulted  time  and 
again  by  persons  who  have  been  sufferers  for  a  considerable  period 
from  what  has  been  pronounced  and  treated  as  neuralgia.  Their 
teeth  had  not  escaped  observation,  but  had  been  examined  and  pro- 
nounced sound.  I  have  found  in  such  mouths  not  unfrequently  this 
operculum  of  gum  overlying  the  wisdom  tooth.  This  I  have  dis- 
sected off,  exposing  compound  caries.  I  have  extracted  such  teeth, 
and  the  patients  have  been  instantly  relieved  of  their  neuro-odon- 
talgia. 

Again ;  these  fleshy  cups,  catching  and  holding,  in  contact  with  the 
soft  parts,  insoluble  particles,  as  often  found  mixed  with  the  food, 


THE   TEETH  AND    THEIR   DISEASES.  203 

will  provoke  periostitis,  or  even  ostitis  of  the  angle  and  ramus  of 
the  jaw.  I  have  seen  the  most  alarming-  inflammatory  attacks  thus 
provoked.  The  tooth  in  these  cases,  as  I  have  somewhere  else  re- 
marked, will  always  be  found  responsive  to  the  stroke  of  an  instru- 
ment. Its  periodonteum  being  inflamed,  common  sense  would  direct 
that  it  be  at  once  extracted ;  but  such  extraction  is  occasionally 
among  the  almost  impossible  things.  A  tooth  so  affected  will  not 
uufrequently  have  but  a  point  erupted  not  larger  than  the  head  of  a 
pin.  In  these  cases  the  best  thing  that  can  be  done  is  to  extract 
the  adjoining  molar;  this  relieves  the  pressure  on  the  ramus  of  the 
jaw,  and  gives  room  for  the  posterior  tooth.  It  will  commonly  yield 
a  cure. 

Trismus,  depending  on  such  lesions,  is  not  uufrequently  the  only 
external  evidence  yielded  of  the  existence  of  the  condition.  The  jaw 
stiffens  and  relaxes,  as  an  odontalgia  will  come  and  go.  In  such 
ephenjeral  cases  it  is  not  at  all  unlikely  that  the  trismus  is  exclu- 
sively a  nervous  action,  or  reflected  irritation, — slight  and  ephemeral 
local  inflammatory  action  being  the  irritant. 

Wisdom  teeth  erupt  from  the  seventeenth  to  the  thirty-fifth  year; 
commonly,  however,  at  about  the  eighteenth  year. 

Some  years  ago  I  treated  a  case  of  trismus,  the  history  of  which 
may  be  given  as  a  very  common  one: 

The  patient,  David  B.,  a  farmer,  after  doing  a  hard  day's  work, 
and  getting  much  overheated,  threw  himself  down,  just  at  early  even- 
ing, in  a  cool  outhouse,  to  rest.  Here  he  fell  asleep,  not  waking 
until  near  midnight.  The  next  day  he  felt  a  soreness  in  the  left  su- 
perior alveolar  arch,  which  soreness  increased  for  two  or  three  days  ; 
after  which  it  deserted  the  teeth  and  passed  to  the  antrum.  Then 
commenced  a  swelling  in  the  integuments  of  the  face,  which  advanced 
until  it  shut  up  completely  the  left  eye.  The  jaws  began  to  stiffen, 
and  ended,  after  three  or  four  days  more,  in  complete  immobility. 

I  was  called  to  the  case,  after  the  lock-jaw  had  existed  nine  weeks, 
the  patient  having  barely  been  able  to  support  life  by  putting  his 
mouth  into  a  basin  filled  with  soup,  and  sucking  the  nutriment 
through  his  teeth.  During  this  time  he  had  been  seen  by  seven 
different  practitioners,  no  one  of  whom  had  seemed  to  appreciate  his 
case,  or,  what  perhaps  is  more  probable,  none  of  whom  had  been 
willing  to  assume  the  trouble  of  it.  The  patient  had  never  told  any 
of  these  gentlemen  about  the  soreness  first  felt  in  his  teeth,  and  no 
one  of  them  had  ever  questioned  him  in  this  direction;  his  single 
complaint  was  of  a  great  weight  about  bis  cheek. 


204  ORAL  DISEASES  AND   SURGERY. 

The  diagnosis  of  the  case  was,  primarily,  periodontitis;  this  in- 
flammation, by  a  double  continuity  of  structure,  had  extended  into 
the  maxillary  sinus,  and  to  the  integuments  of  the  face.  The  inflam- 
mation of  the  antrum  had  been  sufficiently  severe  to  result  in  abscess ; 
abscess  of  the  alveolo-dental  membrane,  and  of  the  lining  membrane 
of  the  cavity.  The  inflammation  of  the  face  had  resulted  in  the 
exudation  of  lymph,  which  lymph  in  a  state  of  coagulation  was  the 
cause  of  the  trismus. 

A  first  eS"ort  was  directed  to  getting  into  the  antrum,  which  I  felt 
well  assured  was  filled  with  pus.  This  was  done  by  prying  out  the 
second  molar  tooth  with  an  elevator,  pushing  it  into  the  mouth 
(from  which,  with  some  trouble,  it  was  afterward  gotten  out);  the 
extraction  was  followed  by  profuse  discharge.  The  patient  described 
the  relief  as  being  immense. 

I  removed  this  particular  tooth,  not  because  it  was  more  carious 
than  its  fellows,  but  because  it  was  somewhat  loose,  and  thus  gave 
evidence  of  the  diseased  condition  of  its  roots.  Again,  it  is  through 
the  alveolus  of  the  palatine  fang  of  this  tooth  that  we  find  our/ 
easiest  and  best  road  to  the  antrum  ;  in  this  case,  as  is  seen,  the 
fang  communicated  with  the  cavity. 

On  the  day  succeeding  the  evacuation  of  the  abscess,  the  patient 
expressed  himself  as  entire!}^  free  from  pain,  his  only  trouble  being 
the  anchylosis,  which  had  not,  as  yet,  relaxed  in  the  least. 

To  the  touch,  all  the  parts  about  the  articular  extremity  of  the 
inferior  maxilla  seemed  completely  indurated.  I  hesitated  to  at- 
tempt the  breaking  up  of  the  parts  mechanically,  fearing  that  thereby 
I  might  do  injury  to  the  important  vessels  which  are  associated  with 
the  head  of  this  bone, — the  internal  carotid  and  internal  maxillary 
arteries.  The  induration  was  of  course  extra-capsular,  and  of 
sufficient  extent  to  have  bound  the  jaw  from  the  glenoid  cavity  to 
the  anterior  border  of  the  masseter  muscle  ;  passive  motion  was 
resorted  to,  but  employed  very  gently.  Blisters  and  sorbefacients 
were  depended  on  The  case  progressed  very  slowly,  the  patient 
having  to  come  to  my  office  every  day  for  fifteen  days ;  at  the  end 
of  this  time,  but  after  removing  other  diseased  teeth  from  his  mouth, 
he  was  dismissed  cured. 

When  one  is  called  to  a  case  of  trismus  of  any  standing,  the 
anchylosis  being  the  result  of  inflammatory  action,  question  may 
arise  as  to  the  propriety  of  mechanically  breaking  up  the  adhesions. 
The  condyloid  extremity  of  the  maxillary  bone  is  assuredly  not 
the  stanchest  part  of  the  body,  and  there  are  anatomical  relations 


THE    TEETH  AND    THEIR   DISEASES.  205 

whicli  it  would  not  be  at  all  pleasant  to  disturb:  these  things  are 
for  the  surgeon  to  decide  upon.  So  far  as  I,  individually,  am  con- 
cerned, I  now  use  mechanical  force  in  all  cases  that  come  under  my 
care,  premising  of  course  that  the  case  is  one  where,  from  inflam- 
mation, the  trismus  depends  on  effused  lymph.  I  am  willing  to  run 
the  risk  for  the  great  and  immediate  good  yielded  ;  some  considera- 
ble experience  in  this  direction  assuring  me  that  such  risk  is  materi- 
ally influenced  by  the  manipulations.  Of  course  I  do  not  mean  to 
recommend  that  attempt  should  be  made  to  open  the  mouth  to  its 
greatest  capacity  with  a  single  turn  of  the  lever  employed,  although 
there  are  cases  where  such  practice  would  be  very  commendable.  I 
have  so  opened  the  mouth  man}^  a  time,  but  not  in  cases  of  long 
standing.  Generally,  the  force  should  be  applied  with  gentleness, 
gain  a  little  one  day,  and  a  little  the  next ;  it  takes  but  a  very  short 
time  to  open  a  mouth  in  this  way;  besides,  if  your  force  is  applied 
with  such  judgment  as  not  to  provoke  vascular  action,  you  will  arouse 
to  co-operation  the  absorbent  system,  the  excitement  acting  as  a 
stimulus  to  it,  and  it  will  be  found  to  do  its  part  vigorously. 

A  person  will  not  unfrequently  be  attacked  with  trismus  after  the 
dental  operation  of  inserting  a  pivot  tooth.  Here  the  lesion  is  more 
than  likely  inflammatory  in  character,  and  the  treatment  is  to  be 
directed  accordingly;  the  root  of  the  tooth  is  in  a  state  of  periodon- 
titis. Cases  of  pure  tetanus,  however,  have  had  origin  in  such  an 
operation.  Where  the  lesion  is  inflammation,  the  parts  are  sore,  and 
tender  to  the  touch. 

A  person  will  sometimes  be  attacked  with  trismus  after  the  plug- 
ging of  a  tooth  with  metal ;  the  attack  comes  on  suddenly;  it  is  a 
reflex  nervous  action,  and  is  always  to  be  esteemed  Of  dangerous 
import.  The  conducting  facility  of  the  metal  irritates  the  nerve 
periphery  in  the  pulp;  this  irritation  is  referi'ed  to  the  Gasserian 
ganglion,  and  thence  reflected  to  the  muscles  of  mastication.  To 
prove  the  existence  of  this  lesion,  direct  the  patient  to  hold  cold 
water  in  contact  with  the  tooth. 

To  treat  a  case  of  this  kind,  remove  the  metal ;  when  the  irrita- 
tion has  subsided,  be  sure  that  before  refilling,  a  non-conducting  sub- 
stance shall  be  placed  between  the  plug  and  the  floor  of  the  cavity; 
or,  because  of  the  thinness  of  the  bony  septum,  it  may  be  desirable 
to  destroy  the  pulp. 

Spasmodic  trismus,  very  persistent,  may  result  from  the  emplo}^- " 
ment  of  two  different  metals  in  the  operation  of  tooth-plugging; 
galvanic  action  is  the  consequence,  and  the  nerve  is  subjected  to  a 


206  ORAL  DISEASES  AND   SURGERY. 

most  harassing  irritation.  To  test  for  this  trouble,  increase  the 
action  by  holding  silver  and  zinc  against  the  plug.  This  test,  how- 
ever, will  irritate  any  super-sensitive  pulp  into  a  state  of  excitement, 
and  is  an  admirable  search-warrant  for  obscure  lesions  of  this  organ. 
The  treatment  consists  of  course  in  the  removal  of  the  plug,  and 
the  medication,  if  required,  of  the  irritated  pulp. 

So  I  might  extend  over  many  pages  the  consideration  of  dental 
lesions  in  connection  with  trismus.  I  have,  however,  written 
enough,  I  presume,  to  direct  a  proper  attention  to  the  subject. 

To  recapitulate:  It  is  suggested  that  many  of  the  cases  of  so- 
called  idiopathic  or  obscure  trismus  will  be  found  to  depend  on  con- 
ditions associated  with  the  dental  arch. 

That  to  insure  permanent  relief,  the  treatment  must  include  the 
primary  lesion. 

That  such  primary  lesions  as  are  described  in  the  chapter  on 
"Anomalies"  are  always  distinguishable. 

That  where  it  is  desirable  to  extract  an  offending  wisdom  tooth, 
and  such  extraction  seems  too  difficult  to  attempt,  the  removal  of 
the  tooth  immediately  anterior  to  it  will  not  unfrequently  be  found 
to  meet  the  indications. 

That  the  immobility  of  the  jaw,  where  acute  inflammatory  action 
exists,  is  to  be  treated  on  general  antiphlogistic  or  phlogistic  princi- 
ples, according  as  it  seems  probable  or  improbable  that  the  inflam- 
mation may  be  resolved. 

That  when  the  acute  action  has  passed,  adhesions  are  to  be 
broken  up  by  mechanical  force  carefully  applied. 

That  mcchanico-dental  lesions  are  not  to  be  overlooked,  but  are  to 
be  searched  for,  and  discovered  secundum  artem. 

Trismits  Traiimaticus. — This  is  that  anchylosis,  true  or  false, 
intra-  or  extra-articular,  dependent  on  local  injury  received.  Of  such 
injuries  we  have,  of  course,  a  great  variety.  Blows  inducing  inflam- 
mation are  among  the  common  causes  ;  a  not  infrequent  cause,  and 
one  difficult  to  be  combated,  resides  in  severe  burns;  sloughs  from 
the  undue  use  of  the  mercurials,  as  exhibited  in  gangrena  oris,  are  to 
be  enumerated  ;  in  short,  we  might  instance  any  condition  in  which 
the  locked-jaw  depends  on  conditions  of  a  local  signification  attended 
with  solutions  or  irregularities  in  the  continuity  of  the  structures. 
A  case  just  dismissed  in  my  own  practice,  in  the  person  of  a  boy 
twelve  years  of  age,  had  the  anchylosis  dependent  on  false  articula- 
tion, the  result  of  injury  done  the  glenoid  fossa  three  years  before 


THE   TEETH  AND    THEIR   DISEASES. 


207 


by  a  blow  upon  the  chin.  The  force  of  this  blow  being  carried  to 
the  joint,  a  chronic  inflammation  had  resulted  in  a  filling  up  of  the 
cavity  on  a  level  with  the  articular  eminence.  While  in  this  peculiar 
situation,  a  species  of  irregular  cavity  had  formed,  which  partially 
accommodated  the  condyle,  compelling,  however,  dislocation  when- 
ever the  jaw  was  forced  open  beyond  a  certain  point.  In  this  case 
a  fair  cure  was  obtained  by  a  tri-weekly  manipulation  of  the  bone, 
resulting,  as  I  infer,  in  a  better-adapted  fossa  through  absorption. 
To  procure  such  motion  as  seemed  demanded,  frequent  luxations 
resulted, — causing  at  first  not  unfrequently  much  trouble  in  the  re- 
duction. This  patient  has  been  advised  to  watch  any  tendency  to 
contraction  Avhich  may  appear,  and  to  keep  it  counterbalanced  by 
rolling  corks  between  his  teeth, — an  excellent  means,  by  the  way, 
where  the  expense  of  instruments  prevents  their  purchase. 

The  use  of  common  bottle-corks  as  a  means  of  overcoming  false 
anchylosis  I  have  employed  for  some  time  with  the  most  satisfactory 
success.  Beginning  an  operation  with  one  of  a  diameter  to  be 
readily  introduced,  increasing  sizes  are  to  be  rolled,  one  after  the 
other,  between  the  teeth,  into  its  place.  Timid  children  will  permit 
the  use  of  corks,  who  entirely  resist  the  screw. 

At  a  late  clinic  of  the  University,  a  young  man  presented  himself 
with  the  lower  jaw  so  fixed  that  only  by  pro- 
foundly etherizing  him  was  it  possible  to  pass 
the  blade  of  a  common  table-knife  between  his 
teeth.  This  condition,  which  had  existed  for 
two  years,  had  resulted  from  a  blow  received 
upon  the  cheek  involving  in  an  inflammatory 
fixedness  the  masseter  muscle.  This  case  was 
treated,  first,  by  subcutaneous  section  of  the 
muscle,  followed  by  the  daily  use  of  the  screw. 
Through  the  use  of  this  instrument  there  is  no 
doubt  of  his  being  kept  comfortable.  He  is 
directed  to  employ  it  daily,  and  never  to  allow 
the  jaws  to  deny  the  introduction  of  two  fingers. 
Without  doubt,  it  will  be  found  that  eventually 
such  modification  of  the  contracted  muscle  will 
result  that  a  fair  cure  may  reasonably  be  anti- 
cipated. The  section  of  the  muscle  in  this  case 
had  of  course  but  the  meaning  of  a8"ording  the 
use  of  the  second  and  true  means  of  cure,  namely,  the  daily  stretch- 
ing of  the  part. 


Fig.  56. 


208 


ORAL  DISEASES  AND   SURGE  BY. 


Fig.  56  represents  the  instrument  employed  in  the  stretching  pro- 
cess, and  which  has  been  furnished  the  patient  for  daily  use:  it  is 
one  devised  or  modified  by  the  ingenious  cutler  to  the  University 
clinic,  Mr.  Kolbe,  and  surpasses  any  other  form  with  which  I  have 
acquaintance  :  by  simply  turning  the  handle,  the  blades,  as  seen  in 
the  drawing,  are  gradually  separated.  The  power  residing  in  this 
instrument  is  sufiBciently  great  to  break  up  any  anchylosis,  true  or 
false,  I  have  ever  seen :  any  jaw  could  be  broken  with  it.  A  neces- 
sary addition,  however,  to  the  instrument,  as  now  constructed,  rs 
felt  to  be  required  in  the  handle  being  made  of  metal  rather  than  of 
wood,  with  the  further  addition  of  a  transverse  bar  to  afl'ord  a  more 
convenient  application  of  the  force.  I  feel  that  I  cannot  too  warmly 
commend  this  instrument  as  the  very  best  now  in  use  ;  it  will  fulfill 
the  requirements  of  any  case  to  which  such  application  of  force  is 
indicated,  while  the  most  careless  patient  may  be  intrusted  to  use  it 
on  his  own  jaws. 

Cases  of  false  anchylosis  will  most  frequently  be  found  extra- 
rather  than  intra-articular ;  or  where  the  condition  has  existed  for  a 
long  time,  say  for  a  year,  then  it  is  reasonably  to  be  inferred  that 
the  two  conditions  are  combined,  that  is,  that  that  portion  of  the 
articular  cavity  which  is  not  used  has  been  modified  by  nutritional 
changes.     Wherever,  however,  the  lesion  of  a  false  anchylosis  is 

situated,  the  philosophy  of  its  re- 
lief consists  in  the  practice  of  pas- 
sive motion, — it  is  really  only  another 
expression  of  the  mode  of  cure  of 
urethral  stricture:  operation  maybe 
necessitated,  but  it  is  only  to  be  prac- 
ticed in  cases  of  urgent  necessity. 

Besides  the  instrument  commended, 
various  others  have  been  devised  for 
the  purpose  of  passive  motion.  Figs. 
57  and  58  show  two  other  forms  of 
such  instruments.  Fig.  57  is  that 
known  as  the  wedge  of  Scultetus. 
Fig.  58  is  a  modification,  as  is  seen, 
of  such  instrument:  neither  of  these 
deserves  mention  as  compared  with 
the  instrument  of  Mr.  Kolbe. 
In  sections  of  the  country  where  the  mercurials  are  freely  used, 
anchylosis  from  sloughing  is  not  uncommon  ;  it  is  frequently  found  in 


Fig. 


THE   TEETH  AND    THEIR   DISEASES.  209 

these  cases  that  the  mucous  aspect  of  the  cheek  has  been  converted 
intoadense  unyielding  fibro-cellular  cicatrix,  which  resists  all  attempts 
on  the  part  of  the  depressor  muscles  to  antagonize  it.  In  cases  of 
this  kind,  instrumental  aid  is  found  most  applicable,  and,  if  properly 
and  judiciously  persisted  in,  will  eventuate  in  satisfactory  relief. 
Another  local  cause  of  anchylosis  is  found  in  bridges  of  bone  asso- 
ciating neighboring  parts,  commonly  the  edges  of  the  glenoid  cavity 
with  the  neck  of  the  lower  jaw,  or  it  may  be  that  the  relation  is 
between  the  two  maxillary  bones.  These  bridges  are  not  unfre- 
quently  to  be  broken  and  their  absorption  secured  through  dilata- 
tion conjoined  with  passive  motion  and  the  use  of  sorbefacients. 
In  no  cases,  however,  is  it  more  desirable  to  guard  against  inflam- 
matory results,  and  therefore  such  procedure  is  to  be  conducted  with 
the  same  care  as  is  felt  to  be  necessary  in  breaking  up  anchylosis  in 
the  knee-  or  elbow-joints  ;  a  principle  being,  to  make  haste  slowly  : 
fracture  of  the  neck  luay  readily  attend  rough  manipulation. 
Should  such  an  accident  occur,  the  desirability  of  making  a  false 
joint  may  have  consideration :  if  a  diagnosis  exhibits  complete 
fixedness  of  the  head  of  the  bone  by  a  bony  relation,  then  nothing 
better  might  be  attempted  than  the  creation  of  such  false  joint,  union 
being  prevented  by  passive  motion,  and  inflammation  combated 
through  the  agency  of  antiphlogistics,  local  and  general,  as  might 
seem  demanded. 

Cases  occur  where  the  only  possible  prospect  of  relief  is  found 
in  the  production  of  such  a  false  joint  by  operation  particularly  di- 
rected to  that  end.  Such  mode  of  procedure  suggests  itself  on 
review  of  the  famous  operation  made  many  years  back  on  the  femur 
of  a  sailor,  by  Dr.  J.  Rhea  Barton,  in  which  a  flexed  limb  was 
restored  to  usefulness  by  the  removal  of  a  V-shaped  wedge,  thus 
allowing  the  leg  to  be  extended.  Both  Rizzoli  and  Esmarch,  acting 
on  such  principle,  have  been  able  to  report  satisfactory  results. 
The  operation  as  practiced  by  the  first-named  of  these  gentlemen 
consists  in  simply  dividing  the  jaw  by  a  delicate  saw — the  chain 
saw  may  be  employed — in  front  of  the  lesion.  Esmarch  removes  a 
V-shaped  wedge,  the  base  being  below,  such  passive  motive  being 
at  once  exercised  as  shall  prevent  union  of  the  separated  parts. 
Practicing  either  of  these  operations,  the  surgeon  will  become  sat- 
isfied that  they  are  only  to  be  resorted  to  in  the  absolutely  compul- 
sory cases. 

A  case  illustrative  of  the  practice  of  Rizzoli  is  thus  recorded : 
"  At  the  time  of  admission  of  patient  into  hospital  the  left  cheek 

U 


210  ORAL  DISEASES  AND   SURGERY. 

was  more  depressed  than  that  of  the  opposite  side,  and  an  explora- 
tion being  made  along  the  horizontal  ramus  of  the  jaw,  the  fact  was 
established  of  the  loss  of  osseous  substance  near  the  posterior  angle 
of  the  jaw.  The  finger,  when  introduced  inside  the  cheek,  was  also 
stopped  by  strong  adhesions  of  cicatricial  tissue,  and  the  teeth  were 
to  be  found  in  their  alveoli,  all  except  the  two  upper  incisors,  the  ab- 
sence of  which  allowed  of  the  introduction  of  some  liquid  nutriment. 

"  The  patient  being  seated,  and  her  head  supported  against  the 
breast  of  an  assistant,  while  another  drew  down  the  lower  jaw,  the 
operator  made  an  incision  in  the  cul-de-sac  which  united  the  lip  and 
gum  of  that  side,  exactly  at  the  space  which  corresponds  to  the 
second  and  third  molars;  this  incision  divided  not  only  the  mucous 
membrane,  but  also  the  subjacent  soft  parts,  so  as  to  lay  bare  the 
lower  border  of  the  jaw;  by  this  wound  was  then  introduced  the 
straight  and  blunt  branch  of  the  bone  forceps,  which  embraced  the 
internal  border  of  the  jaw,  so  that  the  cutting  edge  of  the  instru- 
ment was  easily  placed  on  the  outside.  A  slight  force  only  was 
necessarily  required  to  completely  divide  the  maxilla  at  one  stroke, 
and  thus  restore  to  the  jaw  the  motion  which  had  been  lost  for 
eight  years.  The  operation  is  alluded  to  as  not  being  interrupted 
by  any  complications,  either  during  or  after  its  performance.  The 
patient,  a  girl,  is  reported  as  being  quite  cured,  able  to  separate  her 
jaws  widely  ;  to  chew  her  food,  to  eat,  drink,  laugh,  and  speak,  as 
in  her  normal  state." 

A  case  of  bony  anchylosis  presented  in  the  clinic  of  the  Pennsyl- 
vania Hospital,  operated  on  by  Dr.  T.  G.  Morton,  has  the  following 
history.  It  serves  excellently  well  as  a  type  of  practice  in  its 
direction. 

"Charles  H.  Robinson,"  says  Dr.  Morton,  "aged  eight  years, 
was  brought  to  me  in  October,  1869,  from  Tallahassee,  Florida,  with 
an  anchylosed  condition  of  the  jaws.  In  1865  the  child  had  been 
mercurialized  for  a  long-continued  bilious  remittent  fever;  following 
this,  very  serious  and  extensive  ulceration  of  the  mucous  membrane 
of  the  mouth  resulted,  and  a  slough  on  the  left  side  of  the  face 
opened  a  communication  through  the  cheek  at  a  point  corresponding 
with  the  second  molar  tooth,  and  whicli  involved  the  parotid  duct, 
through  which  for  a  considerable  period  saliva  freely  flowed  ;  an 
abscess  behind  the  ear  also  developed,  which  discharged  for  a  long 
time.  The  health  of  the  child  was  very  seriously  impaired,  and  there 
was  almost  an  entire  arrest  of  bodily  development.  With  the  closure 
and  final  cicatrization  of  the  parotid  fistule  and  the  healing  of  the 


THE   TEETH  AND    THEIR   DISEASES.  211 

ulceration  of  the  mouth,  permanent  bony  closure  of  the  jaws  followed, 
and  for  nearly  five  years  the  child  had  been  fed  entirely  upon  liquid 
food.  On  examination,  I  found  the  boy  irritable,  puny,  and  quite  feeble. 
The  spleen  was  greatly  enlarged  and  quite  hard  ;  complete  osseous 
anchylosis  formed  the  bond  of  union  between  the  upper  and  lower 
jaws  near  the  ramus  on  the  left  side,  corresponding  apparently  to 
the  seat  of  the  original  slough  of  the  soft  parts.  The  cicatrix  was 
here  firmly  attached.  On  the  right  side  of  the  mouth  there  was  no 
attachment  of  bone  and  soft  parts;  the  finger  or  probe  could  be 
readily  insinuated  between  the  alveoli  and  the  cheek ;  the  teeth 
were  very  brittle,  irregularly  notched, — and  many  had  crumbled  off, 
leaving  numerous  openings  through  which  the  child  received  nour- 
ishment. Generous  liquid  diet  and  the  comp.  syr.  of  the  phos- 
phates were  prescribed. 

"Oct.  6. — Admitted  the  boy  as  a  private  patient  into  the  Pennsyl- 
vania Hospital. 

"Oct.  8. — After  etherization,  an  attempt  was  made  to  force  the 
jaws  asunder  with  a  dilator,  but  the  teeth  were  so  friable  that  this 
was  abandoned.  A  curved  incision  was  then  made  through  the 
cheek  to  the  angle  of  the  mouth  on  the  left  side,  and  the  flaps  were 
dissected  up.  This  exposed  a  bony  bridge,  extending  from  the  upper 
to  lower  maxilla,  about  an  inch  in  breadth  and  an  inch  and  a  half 
in  length  and  of  considerable  thickness  and  extreme  density.  There 
was  apparently  no  articular  trouble.  Cutting  forceps  made  but 
little  impression  on  the  deposit,  and  the  bridge  was  then  removed 
by  the  saw.  After  the  removal  of  this,  the  dilator  was  introduced 
and  the  jaws  separated  one  and  six-eighths  of  an  inch.  The  external 
wound  was  united  by  silver  sutures,  and  healed  kindly ;  extreme 
dilatation  was  kept  up  by  plugs  of  wood  for  several  days.  The 
lad's  general  health  continued  to  improve,  and  he  was  able  to  mas- 
ticate his  food  quite  well,  which  was  a  source  of  great  pleasure,  not 
having  tasted  solid  food  for  so  long  a  time.  Recovery  was  rapid, 
although  prostrated  from  loss  of  blood  at  the  operation  ;  yet  he 
improved  daily,  and  was  discharged  November  6,  1869,  cured.  One 
year  afterwards  he  had  good  motion  in  his  jaws.  I  have  not  since 
heard  of  his  state  of  health." 

In  such  conditions  of  anchylosis  as  depend  strictly  upon  cicatrices, 
the  propriety  is  always  to  be  considered  of  a  plastic  operation,  which, 
removing  the  deformed  tissue,  shall  replace  it  with  that  which  is 
normal,  secured  from  some  convenient  part  in  the  immediate  neigh- 
borhood.    If  the  cicatrix  to  be  replaced  be  small,  adjoining  portions 


212  ORAL  DISEASES  AND  SURGERY. 

of  tlie  cheek  may  furnish  the  required  material;  if,  on  the  contrary, 
it  be  large,  the  neck  will  have  to  be  depended  on,  or  it  may  seem  pre- 
ferable to  employ  the  Italian  method  of  taking  a  flap  from  the  arm. 
The  principle  of  the  operation  consists  in  mapping  out  on  the  part 
from  which  the  flap  is  to  be  made  such  extent  and  shape  of  surface 
as  shall  replace  that  designed  to  be  removed.  The  cicatrix  being 
dissected  out,  and  all  bleeding  checked,  the  flap  as  marked  is  raised, 
leaving  it  attached  alone  by  its  pedicle  ;  and  when  hemorrhage  in 
this  also  has  been  controlled,  and  the  surfaces  begin  to  glaze,  it  is 
carefully  to  be  turned  on  the  pedicle  into  its  new  position,  and,  being 
fixed  by  stitches,  is  to  receive  the  attention  required  by  wounds  in 
general.  The  space  left  by  the  removal  of  the  flap  is  to  be  drawn 
together  by  stitches,  adhesive  strips,  or  other  convenient  means. 
Before  undertaking  a  plastic  operation,  however,  nothing  is  more 
necessary  than  to  possess  an  appreciation  of  the  reparative  and 
nutritional  powers  of  the  patient.  To  operate  on  a  person  in  a 
typhoid  state,  or  on  one  the  plasticity  of  whose  blood  is  destroyed 
by  the  influences  of  syphilis,  scrofulosis,  scorbutus,  or  mercurializa- 
tion,  would  be  simply  to  court  failure. 

"Many  cases  of  the  disease  atrasia  oris,  or  closure  of  the  mouth, 
are  reported  as  presenting  themselves  to  the  notice  of  those  attend- 
ing the  medical  charities  of  Calcutta.  It  would  appear  that  there 
are  here  two  very  common  forms  of  this  disease  :  one  in  which  the 
mucous  membrane  covering  the  front  of  the  ramus  of  the  lower  jaw 
has  been  inflamed,  and,  subsequently  contracting,  causes  closure  of 
the  teeth,  without  narrowing,  to  any  considerable  degree,  the  opening 
of  the  lips.  If  the  history  of  these  cases  be  traced,  it  will  be  found 
that  they  have  generalh^  resulted  from  the  cutting  of  the  last  molar 
or  wisdom  tooth  having  caused  the  gum  to  inflame.  The  other 
kind  of  closure  results  from  the  indiscriminate  and  excessive  use  of 
mercury  by  native  practitioners.  The  ulceration  of  the  mucous 
membrane  lining  the  gums  and  cheeks  succeeds  to  the  ptyalism  so 
produced,  and,  on  the  inflammation  subsiding,  the  opposed  ulcerated 
surfaces  unite  and  cause  the  jaws  to  be  closed,  and  the  opening  of 
the  mouth  to  be  contracted.  Both  Dr.  Fayrer  and  Dr.  Partridge, 
surgeons  to  the  charities,  are  accustomed  to  remedy  the  first  accident 
in  the  same  manner,  by  dividing  the  firm  contracted  band  of  mucous 
membrane  with  a  knife  (one  of  the  tenotomy  knives  generally  being 
found  to  be  most  convenient),  and  then  forcing  open  the  jaw  by  an 
extending  trivalve  speculum.  With  a  little  attention  to  dressing,  this 
plan  generally  succeeds.  In  the  other  species  of  atrasia  oris  a  similar 
plan  was  at  first  adopted.     The  adhesions  were  divided  by  a  narrow 


THE   TEETH  AND    THEIR  DISEASES.  213 

knife,  the  jaws  forced  open  by  the  speculum,  if  necessary,  and  lint 
dipped  in  oil  was  pushed  in  to  separate  the  recently-cut  surfaces. 
But  the  disease  treated  by  this  way  alone  had  so  great  a  tendency 
to  relapse,  that  in  a  recent  case  Dr.  Fayrer,  in  addition  to  the  above, 
divided  the  skin  at  the  angles  of  the  mouth  in  a  direction  downward 
and  outward  ;  and  though  at  first  this  occasioned  a  most  lachrymose 
expression  to  the  man's  countenance,  it  ultimately  perfectly  suc- 
ceeded, and  he  left  the  hospital  cured." 

"  Professor  Reina  has  had  occasion  to  observe  four  cases  of  a  new 
form  of  morbid  closure  of  the  mouth,  due,  not  to  anchylosis  of  the 
articulation  of  the  jaw,  but  to  hypertrophic  tliickening  and  indura- 
tion of  the  membranous  muscular  tissues  of  one  or  both  cheeks. 
Syphilis,  scrofula,  or  the  irregular  and  violent  extraction  of  a  molar 
tooth,  were  the  causes  of  this  alteration,  and  the  closure  led  to  much 
difficulty  of  respiration  and  speaking,  and  interposed  an  obstacle  to 
the  introduction  of  solid  food  into  the  mouth,  from  which  resulted 
the  various  consequences  of  insufficient  nutrition. 

"  To  remedy  this  deformity.  Professor  Reina  divided,  by  means 
of  a  bistoury,  the  hypertrophied  tissues,  repeating  the  incisions 
whenever  they  became  necessary,  and  incising  transversely  the  mu- 
cous membrane,  from  the  angle  of  the  jaw  to  the  commissure  of  the 
lips.  The  buccinator  and  orbicularis  oris  were  entirely  divided ;  it 
became  necessary,  also,  more  than  once  to  divide  the  anterior  pillar 
of  the  velum  palati  and  the  glosso-staphylinus  muscle,  and  in  such 
case  the  operator  was,  moreover,  obliged  to  relax  the  corresponding 
side  of  the  tongue,  which  adhered  to  the  interior  of  the  gum.  The 
arterial  hemorrhage  was  combated  successfully  by  compression. 

"  With  the  help  of  conical  pieces  of  cork  introduced  between  the 
teeth,  the  abduction  of  the  jaws  was  facilitated,  at  the  same  time 
that  an  obstacle  was  interposed  to  the  union  of  the  divided  parts. 
Finally,  the  diatheses  were  combated  by  general  treatment,  mercurial 
or  iodized,  according  to  the  special  indications." 

Concluding  this  consideration  of  fixedness  in  the  jaw,  a  resume  of 
the  subject  exhibits  as  causes  of  the  condition, — 

1st.  Spasm  ;  the  treatment  being  of  constitutional  consideration. 

2d.  Anchylosis  by  muscular  induration  ;  the  treatment  being  by 
local  medicaments,  combined  with  the  employment  of  the  dilator. 

3d.  Osseous  anchylosis ;  the  treatment  beirtg  the  breaking  up 
by  section  or  otherwise,  if  permissible,  of  the  bony  bridges. 

4th.  Cicatricial  anchylosis ;  the  treatment  being  by  dilatation 
and  by  plastic  operations. 


CHAPTER    X. 

THE   TEETH    AND    THEIR   DISEASES. 
CAKIES. 

Caries  of  the  teeth  being  a  disease  so  destructive  to  comfort  and 
to  liealth,  and  withal  so  common  as  to  possess  its  illustration  in 
almost  every  human  mouth,  makes  the  subject  felt  as  one  claiming 
earnest  investigation  and  attention. 

Caries  of  a  tooth,  most  simply  expressed,  is  corrosion  of  its  sub- 
stance :  the  disease  may  occur  on  any  part  of  the  surface  of  the 
crown  or  even  the  root,  but  as  a  rule  is  found  to  originate  on  parts 
possessed  of  the  least  self-cleansing  characteristics.  Thus,  it  is 
most  common  to  the  sulci  on  the  grinding  faces  of  the  molars  and 
bicuspidati,  to  the  posterior  depressions  met  with  so  frequently  in 
the  superior  incisor  teeth,  and  to  the  proximal  faces  of  the  teeth 
generally. 

Caries  is  a  disease  of  chemico-vital  relation,  and  is  unfortunately 
most  markedly  of  congenital  association  and  predisposition  :  indeed, 
so  true  is  this,  that  it  may  be  prognosed  that  the  offspring  of  parents 
afflicted  in  this  way  will  be  in  like  manner  afflicted,  and  that,  on  the 
other  hand,  the  children  of  parents  possessing  good  teeth  will  be  in 
like  manner  favored.  So  constant  is  this  analogy  in  the  teeth  of 
parents  and  child,  that  in  most  instances  it  extends  to  the  very 
shape  and  arrangement  of  the  organs,  deformity  insuring  deformity, 
and  regularity  regularity.  One  parent  alone  may  influence  for  good 
or  evil. 

Hereditary  dental  caries  finds  its  explanation  in  likeness  of  condi- 
tion, this  being  of  local  or  constitutional  signification,  or  more  com- 
monly a  conjoining  of  these ;  such  teeth  being  not  only  imperfect 
in  development  in  one  or  more  directions, — in  shape,  in  deficiency  of 
enamel-covering,  in  non-calcification  as  exhibited  in  the  existence 
of  interglobular  spaces,  in  position,  in  tubular  circulation,  in  nerve 
endowment, — but  in  an  equal  number  of  cases  in  lack  of  physiologi- 
cal harmony,  either  in  surrounding  secretions  or  in  the  offices  of 
(214) 


THE   TEETH  AND    THEIR   DISEASES.  215 

nutrition  :  any  or  all  of  these  may  be  the  conditions,  as,  indeed,  re- 
sultant from  them  are  all  cases  of  caries. 
Health  in  the  dental  organism  depends  : 

1.  On  circumstances  associated  with  the  original  formation. 

2.  On  the  shape  of  the  teeth,  their  relation  to  each  other,  and 
their  self-cleansing-  features. 

3.  Constitutional  conditions. 

4.  Character  of  agents  in  contact  with  the  teeth. 

5.  The  absence  of  mechanical  destructives,  as  salivary  calculus, 
the  bands  of  artificial  dentures,  etc. 

6.  Accidental  influences. 

Condition  1.  On  circumstances  associated  loitli  the  original  for- 
mation. 

To  appreciate  the  reasons  explaining  the  inability  on  the  part  of 
certain  dentures  to  fulfill  the  intentions  of  their  creation,  we  are 
compelled  to  consider,  not  unfrequently,  influences  and  associations 
apparently  far  remote  from  them.  That  the  student  may  be  made 
familiar  with  the  principles  involved,  without  which,  indeed,  he  might 
not  otherwise  than  mechanically  treat  carious  teeth,  it  is  proposed  to 
invite  his  attention  to  that  study  and  understanding  of  the  subject 
which  practice  will  demonstrate  as  the  exhibition  of  it  in  a  clinical 
fullness. 

It  is  to  be  assumed,  as  a  premise,  that  like  begets  like ;  therefore 
may  unhealthy  parents  not  fail  to  impress  upon  their  offspring  that 
which  is  of  their  own  constitution.  Of  these  impressions,  some  we 
find  ourselves  able  readily  to  appreciate;  others  are  obscure.  As 
examples,  we  may  refer  to  cachexias,  evident  enough  in  their  indi- 
viduality as  exhibited  over  the  general  system  ;  again,  to  a  transmis- 
sion which  illustrates  itself  alone  in  the  direction  of  the  teeth,  the 
individual  at  large  being  otherwise  healthy.  These  two  type  con- 
ditions exhibit  themselves  to  every  observer. 

Of  the  cachexise  pertaining  markedly  to  the  matter  of  our  investi- 
gation, we  have  three, — scrofulosis,  rickets,  syphilis  ;  cachexias  so 
widely  associated  with  asthenic  conditions,  so  adverse  to  the  healthy 
performance  of  the  nutritional  functions,  that  without  an  under- 
standing of  their  expressions  one  might  not  hope  to  antidote  their 
multitudinous  sequelae.  Because,  therefore,  of  the  marked  impor- 
tance of  the  cachexias,  viewed  in  hereditary  association,  the  student 
is  invited  to  complete,  by  reference  to  the  proper  works,  the  epitome 
here  presented. 


216  OBAL  DISEASES  AND  SURGERY. 


DISTINCTIVE  FEATURES   IN  TYPICAL  CASES  OF  EACH  CON- 
DITION. 

Scrofulosis. — Temperament  lymphatic  ;  abdomen  tumid  ;  com- 
plexion flat  and  pasty;  lips  and  alae  tumid;  saliva  stringy ;  breath 
insipid  and  offensive ;  mucous  membrane  markedly  deficient  in  cir- 
culating activity,  and  much  disposed  to  degenerative  inflammatory 
action ;  lymphatics  enlarged  and  prominent,  especially  those  of  the 
cervical  and  mesenteric  regions,  with  great  disposition  to  suppura- 
tion ;  bones  very  loose  and  spongy  in  their  areolar  tissue,  often  fatty, 
breaking  down  on  slight  provocation  into  caries  and  necrosis ; 
teeth,  alike  with  the  bones,  deficient  in  inorganic  material,  loose  in 
the  character  of  the  intertubular  structure,  more  or  less  deficient  in 
the  integrity  of  the  enamel  cap ;  the  animal  matter  very  susceptible 
to  the  irritating  influences  of  the  unduly  alkaline  oral  fluid;  the  pulp 
pabulum  cacoplastic  to  an  extent  which  almost  completely  stagnates 
the  tubular  circulation,  thus  antagonizing  nutrition;  conditions  of 
dental  health  adverse  without  and  within. 

Rickets. — Physical  force  deficient ;  habits  sluggish  ;  mentality 
small,  with  precocity ;  large  head,  more  commonly  broad  than 
long;  abdomen  prominent  and  heavy;  leanness  ;  general  debility, 
with  indigestion;  puffiness  of  the  extremities;  skin  muddy;  thin- 
ning of  cranial  bones,  together  with  a  plastic  thickening  of  other 
flat  bones  and  enlargement  of  the  extremities  of  the  long  bones  ; 
tendency  to  aplastic  infiltrations  of  the  viscera ;  the  teeth  late  in 
erupting,  slightly  attached  to  their  alveoli,  non-resistive  of  external 
ofi"enses,  which  act  easily  to  a  chemical  disintegration  of  them,  and 
most  apt  by  slight  causes  to  be  pushed  from  their  sockets. 

Syphilis  and  Mercurio- Syphilis. — Stagnant  complexion  ;  lean- 
ness;  atony  of  the  skin  and  muscles;  susceptibility  to  skin-afiTec- 
tions;  poor  and  scanty  hair  ;  interstitial  keratitis,  with  interlaminal 
corneal  lymph  effusions;  stomatitis;  tendency  to  iritis;  the  teeth 
more  or  less  notched  on  their  cutting  edges,  with  pittings  of  the 
enamel ;  mucous  membrane  passively  congested  and  easily  breaking 
down  into  ulcers,  which  ulcers  have  pasty  bottoms;  seroplastic 
effusions  into  the  submucous  Schneiderian  tissue,  interfering  with 
respiration,  inducing  in  the  patient  constant  sniveling ;  eruptions  on 
the  skin  of  a  coppery-red  color;  periosteal  indurations,  with  sub- 
periosteal aplastic  exudates ;  suppuration  of  organs,  as  the  liver, 


THE    TEETH  AND    THEIR   DISEASES.  217 

thymus,  testes;  caries  and  necrosis  of  bones,  particularly  the  turbi- 
nated and  the  maxillae,  and  of  the  teeth. 

ScROFULOSis  —  Scrofula. — This  is  a  constitutional  condition 
having  its  recognition  in  the  cacoplastic  conditions  common  to  it 
and  begotten  of  it,  the  manifestations  of  malnutrition  being  most 
frequently  met  with  in  the  skin,  mucous  membrane,  hip-  and  knee- 
joints,  and  in  the  lymphatic  glands,  which  latter,  in  their  suppuration, 
present  most  markedly  the  feature  of  a  cheesy  degeneration. 

Scrofula  is  commonly  an  inherited  cachexia,  but  may,  through 
depressing  circumstances,  be  engrafted  into  any  constitution.  Bad 
and  ill-nourishing  or  insufficient  food,  continued  exposure  to  impure 
air,  intemperance,  excessive  venery,  mental  anxiety,  the  effects  of 
severe  courses  of  medication,  secondary  effects  of  poisons, — these 
and  similar  causes  may  induce  the  cachexia. 

A  marked  scrofulous  hereditary  transmission  has  its  expression  in 
the  type  case  given,  but  from  this  it  is  to  be  esteemed  as  shading 
into  the  greatest  variety  of  aspect.  Two  primal  expressions  are  clearly 
to  be  recognized.  These  are  the  fair  and  the  dark;  to  be  again  sub- 
divided into  the  fine  and  the  coarse.  The  fine  is  the  disease  as  exist- 
ing and  exhibiting  itself  in  the  sanguine  temperament;  the  coarse  is 
the  typical  case,  as  exhibited  in  the  sluggish  lymphatic.  It  is  well 
just  here  for  the  reader  studying  this  disease  from  the  standpoint  of 
'dental  caries  to  exclude  the  fair  variety,  and  to  place  it  under  the 
head  of  Tuberculosis, — a  distinction  in  the  conditions  which  one 
most  practically  recognizes  as  relation  with  the  health  of  the  teeth 
and  general  digestive  apparatus  is  concerned  ;  the  typical  form  being 
markedly  provocative  of  dental  disease ;  the  fair  variety  exhibiting 
its  manifestations  in  the  viscera,  and  most  particularly  by  deposits 
in  the  lungs,  leaving  the  teeth  quite  exempt  from  a"ny  impression. 
Hence  in  persons  aEFected  with  phthisis  it  is  not  uncommon  to  find 
the  most  beautiful  and  perfect  dentures.  It  is  to  be  remembered, 
however,  we  are  writing  of  predispositions,  and  not  of  manifestations 
from  active  or  recent  conditions  ;  of  impressions  made  on  the  teeth 
during  the  stage  of  formation  and  development,  and  not  of  impressions 
made  by  the  acquired  disease  on  teeth  whose  period  of  growth  might 
have  been  associated  with  such  vigorous  and  health-yielding  life 
that  the  result  is  not  to  be  easily  overcome. 

Scrofulosis  of  the  lymphatic  type  expresses  that  condition  of  a 
system  in  which  morbid  actirtn  results  on  the  slightest  provocation. 
Every  part  seems  lax  and  incapable  of  self-sustenance.  The  slightest 


218  ORAL    DISEASES  AND  SURGERY. 

injury  produces  inflammatory  action,  yet  of  a  grade  requiring  for 
its  control  stimulation  rather  than  depression.  In  a  word,  it  is  a 
condition  in  which  the  vitalizing  principle  has  no  proper  proportion- 
able correspondence  with  the  matter  of  the  body.  Hence  the  char- 
acteristic sluggishness, — the  body  is  only  half  living,  and  was  so 
born, — the  parents  before  it  lacking  that  fullness  of  force  neces- 
sary to  the  vitalization  of  the  offspring.  No  single  tissue  has  been 
harmoniously  constructed,  the  production  being  to  an  extent  an 
abortion. 

Perhaps  the  student  will  possess  himself  of  a  clearer  conception 
of  scrofulosis  if  we  deny  to  it  the  name  of  a  disease,  and  associate 
it  alone  with  the  idea  of  cachexia;  and  this,  if  we  exclude  from  the 
relation  tuberculosis,  with  its  peculiar  deposit,  one  inflicts  no  vio- 
lence in  doing.  It  is  thus,  from  clinical  ol)servation,  I  have  been 
led  for  myself  to  consider  it,  and  such  understanding  seems  best  to 
conduce  to  antagonizing  its  relations.  We  view  the  house  as  one 
ill  built  and  of  poor  materials,  and  do  what  we  can  to  remedy  the 
deficiency.  It  is  a  condition  in  which  attempts  at  specific  treatment 
have  no  signification:  there  is  no  special  condition  to  combat.  With 
tuberculosis,  the  case  will  most  likely  prove  to  be  different. 

In  conjoining  the  axioms  that  "excitement  must  terminate  in 
exhaustion,"  and  that  "from  nothing  may  nothing  come,"  we  may, 
I  think,  find  the  precedents  and  conditions  of  scrofulosis.  In  an  ani- 
mal body  are  so  much  matter  and  so  much  vitality.  As  the  vis  vitse 
may  be  abstracted  from  one  part  to  minister  to  the  excitation  of  other 
parts,  so  necessarily  must  both  come  to  suffer  ;  the  first  from  an  over- 
stimulation which  begets  hypertrophic  degenerations,  morbid  plastic 
formations  capable  of  organization,  thus  compelling  alteration  in 
physiological  expression  ;  the  second,  from  exhaustion  through  the 
absence  of  its  correlating  force,  thus  denying  the  changes  neces- 
sary to  the  fulfillment  of  functional  life, — breeding,  «.of  necessity, 
debility. 

Over-stimulation,  with  its  consequent  exhaustion,  finds  exam- 
ples in  the  intemperate,  the  venal,  and  the  gluttonous.  Children 
begotten  of  these  in  the  days  of  their  exhaustion,  are  apt  to  be 
possessed  of  evidences  of  the  vices. 

Exhaustion,  on  the  other  hand,  is  found  a  primary  condition,  being 
a  result  of  exposure  to  influeiic(!S  debilitating  in  themselves;  as,  for 
example,  to  poisons,  deprivation  of  proper  food,  insufficiency  of 
clothing,  to  lack  of  cleanliness,  being  rll  housed,  unhealthy  employ- 
ment, continuous  subjection  to  mental  disquietude  or  oppression. 


THE   TEETH  AND    THEIR  DISEASES.  219 

excessive  secretions  and  discharges,  deprivation  of  light  and  sun- 
shine, etc.  We  are  to  assume  that  the  disease  we  study  is  not  a 
materia  peccans  in  the  blood,  but,  as  Billroth  expresses  it,  "  a  debility 
of  the  organization."  Dr.  C.  J.  B.  Williams,  while  admitting  no  dis- 
tinction between  scrofulosis  and  tuberculosis,  yet  describes  the 
condition  as  "a  degradation  of  the  nutritive  material  from  which  old 
textures  are  renewed  and  new  ones  formed,  in  that  in  its  origin  it 
differs  from  the  normal  plasma  or  coagulable  lymph,  not  in  kind,  but 
in  degree  of  vitality  and  capacity  of  organization." 

What  cacoplastic  lymph  is,  we  appreciate.  What  tubercle  is,  we 
do  not  know ;  the  highest  authorities,  in  such  direction,  are  still  at 
issue  concerning  not  only  the  origin,  but  even  the  nature,  of  tubercle. 
Whether,  therefore,  tubercle  is  or  is  not  an  expression  of  struma,  we 
are,  in  our  present  connection,  not  concerned  to  discuss.  Proto- 
plasm, lymph,  is  the  basal  nutritive  agent;  plasma  is  not  self-creat- 
ing or  of  itself,  but  a  product  of  vital  force  acting  on  materials  taken 
for  the  nourishment  of  the  body.  That  organs  be  normal,  pro- 
toplasm must  be  normal.  The  diseased  protoplasm  of  degraded 
parents  —  more  particularly,  perhaps,  that  of  the  mother  —  may  not 
afford  that  nourishment  which  is  the  proper  life  of  a  child;  on  the 
contrary,  it  associates  its  own  degradation  with  all  with  which  it 
may  come  in  association. 

Following  such  line  of  view,  it  Avill  be  recognized  that  we  may  not 
have  any  marked  distinction  between  scrofulosis  and  the  hereditary 
manifestations  of  syphilis,  of  the  mercurial  vice,  or  of  other  parental 
adynamic  transmissions;  and,  therapeutically  viewed,  this  premise 
we  believe  to  be  the  proper  one, — the  principle  of  treatment  being 
found  the  same, — this  being  tonic  medication,  and  having  no  spe- 
cificity to  which  it  is  to  be  directed.  If,  however,  special  organs 
be  specially  affected,  this  would  of  necessity  direct  to  them  particu- 
lar attention,  and  the  treatment,  as  the  part  affected  is  concerned, 
would,  in  local  requirements,  differ, — as,  for  example,  whether  we 
might  have  to  combat  caries  of  the  bone  or  caries  of  the  teeth  ;  the 
constitutional  treatment  may,  however,  only  be  the  same,  and  from 
such  aspect,  what  would  be  the  cure  of  the  one  would  necessarily 
tend  to  the  same  result  in  the  other.  Unfortunately,  however,  as 
the  teeth  are  concerned,  from  the  low  grade  of  their  vitality,  and, 
consequently,  the  inactivity  in  their  molecular  changes,  counter-im- 
pressions are  long  in  being  made  ;  therefore,  in  the  constitutional 
caries  of  these  organs,  too  much  attention  cannot  be  given  to  the 
local  relations.     The  fluids  of  the  mouth  are,  if  adverse,  to  be  neu- 


220  ORAL  DISEASES  AND  SUBGERY. 

tralized  to  the  required  non-antagonism.  Cleanliness  is  to  be  par- 
ticularly insisted  on,  and  all  cavities  are  to  be  filled  or  filed  away,  as 
may  seem  indicated. 

Rachitis — Innutrio  Ossium. — A  constitutional  disease,  having  its 
predisposition  in  hereditary  transmission :  characterized  by  non- 
solidification  of  the  growing  layers  of  bone,  by  the  formation  of 
medullary  cavities  in  the  older  or  more  mature  bones,  thus  render- 
ing the  bony  laminae  thin  and  Ijrittle  (Yirchow),  and  by  excess  in  the 
formation  of  phosphoric  and  lactic  acids,  with  great  excess  of  the 
earthy  phosphates. 

It  is  not  to'  be  maintained  that  rickets  is  a  constitutional  disease, 
save  in  the  sense  of  predisposition.  Neither  is  it  to  be  affirmed  that 
it  possesses  a  constancy  of  expression  which  allows  of  a  common 
formulary  for  a  description  of  its  diagnostic  signs ;  on  the  contrary, 
the  expressions  vary  from  the  most  simple  manifestations  of  a 
disturbed  nutrition  to  a  specific  alteration  in  the  bones,  which  renders 
them,  from  lack  of  inorganic  constituents,  incapable  of  performing 
their  functions.  Indeed,  it  is  probable  that  degrees  of  rickets  may 
quite  frequently  present  themselves  and  yet  be  overlooked.  While, 
as  suggested  by  Hillier,  the  secondary  diseases,  such  as  bronchitis, 
collapse  of  the  lungs,  atrophy,  measles,  hooping-cough,  or  convul- 
sions, are  recognized,  the  primary  disease,  which  renders  these  sec- 
ondary conditions  fatal,  is  quite  ignored. 

As  rachitis  is  congenital,  or  as  it  associates  itself  with  the  denti- 
tional  periods,  so  are  manifested  the  effects  of  the  condition  upon  the 
health  of  the  teeth, — these  organs  being  delayed  in  their  development, 
disposed  to  caries,  and  not  unfrequently  of  such  loose  relation  to  their 
sockets  from  aplastic  softening  of  the  peridental  tissue  as  to  be  dis- 
placed by  slight  force:  the  periodonteum,  and  also  the  pulp,  may  be 
affirmed  to  present  evidences  of  the  common  amyloid  degeneration 
as  seen  in  the  viscera,  particularly  in  the  liver  and  spleen.  The 
delay  in  the  cutting  of  the  teeth  is  simply  delay  in  development, 
the  albuminoid  pulp  lacking  organic  force  to  secrete  dentinal  tissue; 
while,  as  is  to  be  inferred,  that  which  is  made  is  of  such  imper- 
fect organization,  so  mottled  with  uncalcified  spots, — interglobular 
spaces, — as  to  be  rendered  quite  incapable  of  resisting  that  excess 
of  lactic  acid  found  in  the  secretions  coming  in  contact  with  it. 

History. — Rachitis  is  a  disease  having  perhaps  in  all  cases  the 
association  of  hereditary  predisposition,  yet,  like  scrofulosis,  exist- 


THE   TEETH  AND    THEIR  DISEASES.  221 

ing  ill  such  variety  of  aspects  and  in  such  states  of  modification  as 
to  make  it  not  easy  of  recognition  through  any  constant  signs. 
These  modifications  are  of  a  twofold  nature.  First,  the  character 
of  the  hereditary  impression.  Second,  the  associative  surroundings 
and  conditions  of  the  patient.  Sir  William  Jenner,  whose  lectures 
on  the  subject  are  worthy  of  all  respect  and  attention,  speaks  of  this 
disease  as  "  without  question  the  most  common,  the  most  important, 
and,  in  its  effects,  the  most  fatal  of  all  that  exclusively  affect  chil- 
dren." Hillier  (Meigs  and  Pepper)  presents  a  table  showing  the 
proportion  borne  by  the  number  of  cases  of  this  disease  to  the  total 
number  of  out-patients  treated  at  the  Hospital  for  Sick  Children, 
London,  from  which  calculation  exhibits  that  of  128,656  children 
treated  during  thirteen  years  (1854-66)  not  less  than  8419,  or  6.5 
per  cent.,  were  rachitic;  and  in  some  years  the  proportion  of  such 
patients  rose  as  high  as  9  per  cent.  In  London  hospitals  and  in  the 
other  great  hospitals  gathering  in  the  poverty  and  degradation  of 
any  large  city,  such  percentage  does  not  strike  us  as  at  all  a  matter 
for  surprise.  It  must  be  recognized,  however,  as  is  to  be  inferred 
from  home  observation,  that  such  statistics  designate  the  disease  as 
included  in  its  diversified  phases. 

The  cachectic  state  preceding  the  osseous  manifestations  of  rickets 
is  not  generally  to  be  noticed  at  birth,  but  develops  commonly  during 
the  process  of  the  first  dentition,  seldom  appearing  at  a  later  period 
than  during  the  time  of  the  active  stages  of  the  second.  The  incu- 
bation precedes,  however,  the  manifestations  of  the  cachexia,  residing, 
as  we  incline  to  believe,  in  an  original  molecular  impression  :  at  least 
it  is  only  thus  that  we  find  explanation  of  the  organic  impressions 
found  in  the  structure  of  the  deciduous  dentine  and  enamel. 

The  relation  of  rickets  with  scrofulosis  is  found  in  the  pre-associa- 
tion  of  the  two  conditions.  Thus,  "  Whatever  tends  to  produce 
debility  and  anaemia  in  a  mother,  as  too  frequent  pregnancies  or 
prolonged  lactation,  renders  it  probable  that  her  next-born  children 
will  be  rickety."  Jenner  states  "that  it  is  very  common  for  the 
first,  or  the  two  or  three  first-born  children,  to  be  free  from  any 
signs  of  rickets,  and  yet  for  every  subsequent  child  to  be  rickety  ;" 
which  he  explains  by  the  fact  "  that  among  the  poor  the  parents  are 
generally  worse  fed,  worse  clothed,  and  worse  lodged  the  larger  the 
number  of  their  children ;  and  among  the  rich  and  poor  alike,  the 
larger  the  number  of  children,  the  more  has  the  constitutional 
strength  of  the  mother  been  taxed,  and  the  more  likely  is  she  to 
have  lost  in  general  power,"  (M.  and  P.) 


222  OBAL   DISEASES  AND  SURGERY. 

Predisposition  in  a  child  may  be  overbalanced  by  its  prophylaxis. 
Thus,  children  of  wealthy  parents,  even  where  the  antecedents  are 
very  unfavorable,  may  escape  the  evident  expressions  of  rickets  as 
the  result  of  hygienic  antagonisms,  just  as  adverse  conditions  are 
found  to  prove  exciting  causes  to  its  development.  It  is  indeed 
because  the  most  characteristic  expressions  of  this  disease — namel}^, 
affections  of  the  skeleton  —  are  so  influenced  by  outward  circum- 
stances, that  eminent  observers  have  in  some  instances  come  to  deny 
its  existence  among  the  better  classes  ;  though  this  differs  much  from 
the  statement  of  Jenner,  who  asserts  that  he  has  very  often  met  with 
it  among  the  children  of  the  very  wealthy.  We  think,  however, 
that  it  is  to  be  made  a  cardinal  point  that  the  disease  is  not  neces- 
sarilv  to  exhibit  its  osseous  complication  to  have  existence,  and  that 
its  prodroma  are  as  much  the  condition  (in  abstracto)  as  is  the 
observable  softening  itself. 

The  relation  of  rickets  with  hereditary  syphilitic  disease  is 
affirmed  by  Vogel,  who  professes  to  base  the  deduction  from  wide 
clinical  inquiry.  Such  relation  is,  however,  denied  by  Sir  William 
Jenner,  the  denial  being  founded  mainly  on  the  following  facts : 
"  The  parent  who  infects  his  offspring  (with  syphilis)  has  usually 
contracted  the  syphilis  before  marriage,  and  the  children  first  begot- 
ten after  infection  are  those  who  suffer  (from  inherited  syphilis) ; 
while,  as  a  rule,  it  is  only  the  younger  children  of  a  family  that 
suffer  from  rickets."  Sir  William  Jenner  is  also  doubtful  as  to  the 
health  of  the  father  affecting  the  child,  but  throws  the  weight  of  his 
influence  in  that  scale  which  attributes  the  disease  to  insufficient 
nutrition  :  thus  suggesting  the  inference  of  the  direction  in  which 
lies  its  prophylaxis,  and  as  well  indorsing,  without  intention,  the 
oneness  of  cachexia.  Mr.  Lonsdale  expresses  himself  as  having 
invariably  found  "  that  in  all  rickety  children  the  parents  have  had 
little  or  no  milk  for  their  supply,  and  have  been  obliged  to  feed  the 
children  either  partially  or  wholly  with  food  other  than  the  milk  of 
the  mother.  The  mothers  observe  that  the  children  never  grew 
properly  from  the  first,  and  it  is  mainly  the  improper  nature  of  the 
supplementary  food  given  by  hand  which  impairs  the  health  of  the 
child.  The  rearing  of  the  children  of  the  poor  in  London  is  thus 
described  by  Sir  William  Jenner: 

"  For  the  first  two  or  three  days  after  birth  their  tender  stomachs 
are  deranged  by  brown  sugar  and  butter,  castor  oil  and  dill-water, 
gruel  and  starch-water.  As  soon  as  the  mother's  milk  flows,  they 
are,  when  awake,  kept  constantly  at  the  breast;  and  well  for  them 


THE   TEETH  AND    THEIR    DISEASES.  223 

if  they  are  not  again  and  again  castor-oiled  and  dill-watered,  and 
even  treated  with  mercurials.  After  the  first  month,  bread  and 
water  sweetened  with  brown  sugar  is  given  several  times  a  day, 
and  during  the  night  the  child  is,  when  not  too  soundly  asleep,  con- 
stantly at  the  breast.  As  soon  as  the  little  ill-used  creature  can  sit 
erect  on  its  mother's  arm,  it  has,  at  parents'  meal-time,  'a  little  of 
what  we  have,' — meat,  potatoes,  red  herring,  fried  liver,  bacon,  pork, 
and  even  cheese  and  beer  daily,  and  cakes,  raw  fruit,  and  trash  of 
the  most  unwholesome  quality  as  special  treats,  or  as  provocatives 
to  eat,  when  its  stomach  rejects  its  ordinary  diet.  Then,  instead 
of  being  weaned  when  from  ten  to  twelve  months  old,  the  child  is 
kept  at  the  breast  when  the  milk  is  worse  than  useless,  to  the  injury 
of  the  mother's  health,  and  to  the  damage  of  its  after  brothers  and 
sisters,  in  the  hope  that  thus  keeping  it  at  the  breast  may  retard 
the  next  pregnancy."  (Holmes.) 

According  to  M.  Guerin,  there  will  commonly  be  in  rickets  a 
period  of  at  least  six  months  before  the  practitioner  may  feel  assured 
of  the  exact  character  of  the  case,  or  fairly  distinguish  it  from  other 
diseases  to  which  the  prodroma  are  common. 

The  incubative  stage  is  characterized  by  irritations  of  a  gastro- 
intestinal character.  The  stools  are  irregular,  being  sometimes 
scanty,  but  more  commonly  profuse,  marked  by  absence  of  bile,  not 
unfrequently  being  of  leaden  color  and  most  offensive  in  odor.  Some- 
times, however,  and  this  more  particularly  in  the  beginning,  the 
discharges  are  greenish,  of  a  serous  or  watery  consistence,  with  a 
smell  which  has  been  compared  to  that  of  rotten  meat.  The  .child 
is  found  to  run  down  as  from  a  chronic  diarrhoea. 

A  marked  symptom  soon  supervening,  and  one  which  is  not  un- 
frequently the  first  that  suggests  to  the  practitioner  the  peculiar 
nature  of  the  disease,  is  profuse  perspiration  of  the  head.  These 
perspirations  weaken  the  child  very  rapidly,  and,  when  in  progress, 
the  evidences  of  congestion  are  to  be  observed  in  all  the  neighboring 
vessels, — veins  and  arteries. 

Associated  with  this  sweating,  and  more  or  less  synchronous 
with  it,  is  a  general  soreness  of  the  body,  the  little  patient  in  many 
cases  lying  motionless  for  hours,  rather  than  endure  the  discomfort 
of  moving.  Such  soreness  has  always  more  or  less  connected  with  it 
a  desire  on  the  part  of  the  child  to  be  cool,  even  in  winter;  such 
patients  seeming  most  comfortable  when  lying  entirely  uncovered, — 
a  fact  sutBciently  demonstrated  in  hospital  wards. 


224  ORAL  DISEASES  AND  SUBGERY. 

The  deformities  of  the  head  in  rickets  are  thus  distinguished  by 
Sir  William  Jenner:* 

1.  By  thickening  of  the  bones.  This  is  usually  most  perceptible 
just  outside  the  sutures,  the  situation  of  the  sutures  being  indicated 
by  deep  furrows. 

2.  By  the  length  of  time  the  anterior  fontanelle  remains  open.  In 
the  healthy  child,  it  closes  completely  before  the  expiration  of  the 
second  year.     In  the  rickety  child,  it  is  often  open  at  that  period. 

3.  By  the  relative  length  of  the  antero-posterior  diameter  of  the 
head. 

4.  By  the  height,  squareness,  and  projection  of  the  forehead.  The 
first  two  of  these  peculiarities  of  the  rickety  head  are  the  result  of 
the  affection  of  the  bones;  the  last  two  are  chiefly  due  to  disease  of 
the  cerebrum. 

The  succeeding  conditions  are  those  which  associate  themselves 
with  bone  disease. 

The  process  of  dentition  (Holmes)  is  invariably  arrested  or  de- 
layed ;  and  if  the  teeth  are  formed,  they  soon  decay,  or  they  early 
fall  from  their  sockets,  the  incisors  frequently  being  lost  before  the 
second  molars  of  the  first  set  have  made  their  way  through  the 
gums.  So  important  is  the  knowledge  to  be  derived  from  the  progress 
of  dentition,  that  Sir  William  Jenner  lays  down  the  following  rule 
of  practice  : 

"  If  a  child  pass  over  the  ninth  month  without  teeth,  you  should 
carefully  inquire  for  the  cause.  It  may  be  that  an  acute  illness  has 
retarded  dentition.  It  may  be  (and  this  is  infinitely  the  most 
common  cause  of  late  dentition)  that  the  child  is  rickety.  Fail  not, 
then,  when  called  to  a  child  in  whom  the  teeth  are  late  in  appearing, 
to  look  if  it  be  rickety,  for  if  you  do  fail  to  look  for  rickets,  you  will 
most  likely  attribute  to  the  irritation  of  teething  symptoms  which 
are  the  consequences  of  the  rickety  diathesis, — the  late  dentition  in 
rickets  being  in  itself  merely  a  symptom  of  the  general  disorder. 
The  rickety  deformities  ma}'  be  very  trifling,  and  yet  the  teeth  con- 
siderably retarded  in  their  development." 

The  inorganic  constituents  of  bone — the  earthy  phosphates — are 
sometimes  found  in  great  excess  in  the  urine,  a  case  being  recorded 
by  Mr.  Solly  where  such  excess  was  fourfold.  It  is  perhaps,  how- 
ever, as  frequently  the  case  that  the  deficiency  in  lime-salts  results 

*  Medical  Times  and  Gazette,  18G0.  See  also  Holmes's  System  of  Surgery, 
vol.  i. 


THE   TEETH  AND    THEIB  DISEASES.  225 

from  non-ingress  of  these  materials,  without  change  in  the  egress ; 
while  a  hypothesis  founded  on  the  observations  of  Marchand 
attributes  the  absence  of  the  phosphates  to  their  dissolution  by  lactic 
acid.  This  is  effected,  as  inferred,  by  the  lactic  acid  changing  the 
carbonate  and  phosphate  of  lime  into  the  soluble  lactate,  which  in 
this  state  is  capable  of  being  taken  up  and  carried  from  the  system  ; 
or,  when  not  removed  in  this  way,  it  might  be  possible  for  the 
organic  basis  of  bone  to  be  dissolved  by  the  inflammatory  neoplasia 
with  a  breaking  down  of  the  chalky  substance,  whose  molecules  might 
either  be  dissolved  or  carried  away. 

In  rachitis,  according  to  Yirchow,  the  bones  are  histologically 
formed,  except  that  the  bone-cartilage  has  no  chalky  salts, — or,  at 
least,  little  in  proportion  to  their  requirements.  Billroth  directs 
attention  to  the  effect  of  the  dyscrasia  upon  dentition.  The  treat- 
ment he  regards  as  of  that  general  nature  which  pertains  to  the 
building  up  of  the  health  of  the  patient.  As  food,  it  may  not  be 
well  to  use  too  freely  of  bread,  potatoes,  mush,  or  flatulent  vegeta- 
bles, but  the  child  is  to  partake  freely  of  meat,  eggs,  milk,  and 
all  nitrogenous  diet.  Billroth,  in  discussing  the  use  of  preparations 
of  lime,  expresses  a  doubt  as  to  any  benefit  that  may  arise  from  their 
employment,  deeming  it  not  impossible  that  rachitis  may  be  a  disease 
of  digestion  in  which  such  preparations  may  not  be  absorbed, — which 
view  is  indeed  a  common  one  among  American  physicians. 

A  rachitic  child  should  be  daily  bathed  in  salt  water,  lukewarm 
or  cold,  as  seems  most  suitable  ;  the  dress  should  be  adapted  to 
the  season ;  and  daily  exercise,  active  or  passive,  is  to  be  taken  in 
the  sunlight  and  open  air.  The  use  of  cod-liver  oil  has  the  recom- 
mendation universally  both  of  European  and  American  practitioners. 
Yogel  asserts  that  rickets  may  be  cured  by  the  use  of  cod-liver  oil 
alone.  Rickety  children  tolerate  the  oil  well,  and  are  usually  found 
to  become  fond  of  it.  Iron  and  the  vegetable  tonics  are  almost 
always  found  useful;  while  beer  or  wine  in  limited  quantities,  grad- 
uated to  the  age  and  condition  of  the  patient,  will  sometimes  be 
found  to  meet  the  indications  most  admirably. 

Syphilis. — Yiewnng  the  relations  of  this  disease  with  the  health 
of  the  teeth,  we  necessaril}^  embrace,  or,  indeed,  perhaps  more  fully 
treat  of,  the  association  of  the  mercurial  poison  than  that  of 
syphilis  itself,  inasmuch  as  the  two  are  found  so  constantly  combined 
that  it  may  be  esteemed  a  matter  of  some  doubt  if  the  single  rela- 

15 


220  ORAL  DISEASES  AND  SURGERY. 

tion  is  ever  met  with  in  the  hereditary  aspect.  I  use  the  term  in 
the  fullest  sense  of  heredity,  not  embracing  the  cases  in  which  a 
foetus  receives  inoculation  in  passing  over  an  unhealed  vaginal 
chancre,  or  where  the  father,  having  incipient  secondary  manifesta- 
tions, extends  such  to  the  impregnating  sperm. 

That  the  syphilitic  poison  impresses  of  itself  the  growing  teeth 
is  made  evident  by  the  very  frequent  imperfect  development  of  these 
organs  found  in  association  with  the  disease,  and  which,  outside  the 
specificity,  may  not  well  be  accounted  for.  I  allude  to  the  notching, 
the  pitting,  and  the  small  size, — conditions  which  may  fairly  be 
presumed  not  to  have  special  relation  with  the  second  of  the  poisons, 
inasmuch  as  this  renders  its  expression  in  that  general  molecular 
depression  which  is  seen  in  the  lowered  vitality  of  the  parts  at 
large,  and  which  has  just  been  considered  under  the  head  of  scrofu- 
losis. 

The  pittings  in  the  enamel  of  the  teeth,  and  the  irregularities  of 
the  cutting  faces,  represent  expressions  believed  to  be  found  only 
in  connection  with  hereditary  syphilis,  and  which  it  seems  proven 
may  be  transmitted  to  the  third  generation.  These  deformities  are 
seen  most  generally  in  the  second  set  alone  ;  the  first  are  liable  to 
early  decay,  but  not  so  much  to  the  malformations.  The  impres- 
sions are  confined  to  the  anterior  six  teeth,  and  vary  from  the  most 
marked  examples  to  scarcely  perceptible  irregularities  of  the  cutting 
edges,  or  an  occasional  depression  seen  here  and  there  upon  the 
anterior  face,  or  it  may  be  the  posterior, — most  frequently,  however, 
upon  the  anterior  alone.  Observations  will  be  found  to  greatly  vary 
concerning  the  existence  of  any  constancy  in  phenomenal  expres- 
sions of  the  teeth  in  this  relation. 

The  diagnostic  signs  and  conditions  of  acquired  syphilis,  it  is  to 
be  taken  for  granted,  are  known  to  the  reader.  With  these  we  have 
nothing  to  do,  inasmuch  as  the  influences  we  consider  are  those 
impressed  in  utero. 

I  think  I  will  be  borne  out  in  the  assumption  that  it  is  only  in 
earliest  infancy  that  syphilis  expresses  itself  with  that  distinctness 
which,  outside  of  the  history,  renders  its  diagnosis  reliable  ;  and, 
further,  that  parents-afflicted  with  the  advanced  tertiary  stage  of  the 
disease  do  not  transmit  the  disease  with  diagnostic  individuality,  but 
rather  that  in  the  term  scrofulosis  lies  its  expression,  that  the  con- 
dition of  the  syphilides  is  the  state  in  which  the  transmission  retains 
specificity, — the  tertiary  stage  expressing  the  exhaustion  of  the 
disease  in  the  molecular  degeneration  induced  of  it, — and  that  when 


THE   TEETH  AND    THEIR   DISEASES.  227 

transmitted  in  such  secondary  stage,  its  continuous  course  in  tiie 
child  is  apt  to  be  the  same  as  that  in  the  parent. 

As  a  syphilitic  impression  has  been  made  on  the  foetus  with  the 
condition  of  the  parent  or  parents  most  closely  allied  to  the  first  of 
the  secondary  manifestations,  so  will  the  child  exhibit  raslies,  or  the 
graver  expressions  of  mucous  inflammation.  Thus,  without  per- 
haps proper  attention  to  such  data,  it  has  become  common  to  write 
of  the  confounding  of  the  secondary  with  tertiary  manifestations, — 
a  confusion  that  does,  however,  without  doubt,  occasionally  e.xist, 
owing  to  the  general  slighter  resistive  force  of  particular  infants, 
just,  indeed,  as  the  same  confounding  of  conditions  is  not  unfre- 
quently  met  with  in  the  adult. 

The  expressions  of  the  transmission  of  uncomplicated  syphilis 
show  themselves  commonly  by  the  third  week  ;  although  instances 
enough  occur  where  the  child  is  born  with  such  evidences  ;  or  the 
little  patient  may  live  for  a  year  without  any  sign  of  the  disease  ex- 
hibiting itself, — seldom  longer,  however. 

Hereditary  syphilis  differs  of  course  from  the  acquired  in  having 
no  primary  stage.  As  in  my  own  observation  I  have  met  with  the 
condition,  the  most  common  manifestation  is  found  in  that  morbid 
congestive  state  of  the  Schneiderian  mucous  membrane,  which, 
as  in  a  common  cold,  yields  what  the  parents  call  snuffles,  being 
universally  attributed  to  the  child's  having  a  cold.  Unfortunately, 
however,  such  colds  do  not  tend  to  self-cure,  but  in  very  many 
instances,  perhaps  in  a  majority,  produce  changes  in  the  nasal 
relations  which  result  in  a  flatness  of  the  bridge  of  the  organ,  bearing 
the  sign  throughout  life,  and  which  is  justly  to  be  esteemed  as 
markedly  diagnostic  of  the  hereditary  association. 

A  child  afflicted  with  this  disease  may,  without  doubt,  be  born 
plump  and  apparently  vigorous ;  but  such  vigor,  as  remarked  by  all 
observers,  proves  evanescent.  After  a  few  days,  or  weeks,  or,  it 
may  be,  months,  the  child  will  begin  to  emaciate,  the  skin  wrinkles 
from  absorption  of  the  underlying  fat,  the  face  shows  discolorations, 
and  a  peculiar  expression  of  premature  age  comes  on  :  this  expres- 
sion of  age  is  so  marked  and  persistent  that  it  will  be  found  to 
characterize  every  child,  young  or  old,  afflicted  with  transmitted 
syphilis.  I  have  this  moment  in  my  memory  the  faces  of  a  number 
of  little  girls  who  are  in  the  habit  of  occasionally  presenting  them- 
selves at  my  clinic,  and,  although  the  eldest  is  not  over  thirteen, 
they  have,  all,  the  demure  expression  of  years  quite  in  advance  of 
them.  Yet  such  expression,  1  remark,  seems  influenced  by  the  stage  of 


228  ORAL  DISEASES  AND   SURGERY. 

their  affection,  those  afflicted  with  bone-troubles  being  usually  older- 
looking  (in  proportion  to  their  years)  than  others  presenting  alone 
the  skin-manifestations. 

The  appearance  of  pemphigus  soon  after  birth,  associated  with 
the  ordinary  early  symptoms,  is  deemed  by  experienced  observers 
very  diagnostic.  Interstitial  keratitis  with  iuter-laminar  lymph-elfu- 
sions  is  associated  alone  with  the  hereditary  form  of  syphilis, — iritis 
being  an  expression  of  the  acquired  form.  In  hereditary  syphilis 
the  manifestations  are  sj^nmetrical ;  in  the  acquired  form  they  are 
rarely  so.  The  manifestations  of  the  hereditary  form  run  one  into 
the  other;  those  of  the  acquired  tend  to  remain  distinct. 

From  this  necessarily  limited  discussion  of  the  hereditary  vices 
we  pass  to  that  aspect  of  the  subject  which  considers  tlie  relation 
of  developing  teeth  with  nutritional  instrumentalities. 

In  viewing,  from  a  systemic  standpoint,  the  composition  of  the 
teeth,  we  have  primarily  to  remark  that  the  component  parts  are 
formed  from  and  preserved  by  the  chemico-vital  relationship  exist- 
ing between  blood  and  parts  to  be  nourished.  We  recognize,  and 
know,  that  in  the  fluid  which  we  denominate  blood  resides  the 
element  of  nutrition,  and  that  as  this  material  is  well  or  ill  adapted 
to  meet  the  requirements  of  the  different  tissues,  so  are  these  tissues 
found  to  be  in  vai'ying  states  of  health.  We  infer  that  blood,  rich 
in  the  elements  of  tooth-structure,  is  capable  of  yielding  good  teeth, 
provided  the  process  of  assimilation  resides  to  a  proper  extent  in  the 
part  to  be  built  up  and  nourished :  so  that  the  study  of  caries,  from 
the  constitutional  standpoint,  consists  in  looking  at  the  condition 
of  the  blood  and  the  amount  of  vital  force  residing  in  the  teeth 
themselves. 

A  tooth  in  its  composition  is  made  up  of  cementum,  dentine, 
enamel,  and  pulp  substance.  Excluding  the  pulp  substance,  we 
find,  with  some  variation,  the  relative  proportions  of  organic  and 
inorganic  matter  to  be  as  follows : 

Cementum. 

Organic  matter 29-27 

Inorganic  matter.. 70-73 

The  character  of  this  inorganic  material  we  find,  by  a  more  com- 
plete analysis,  to  be  as  follows  :  phosphate  of  lime,  fluate  of  lime, 
carbonate  of  lime,  phosphate  of  magnesia,  salts. 

The  composition  of  healthy  blood  yields  the  following  analysis: 


Jontine. 

Enamel 

28  70 

3 -.59 

71  30 

96-41 

THE    TEETH  AXD    THEIR   DISEASES.  229 

Water 780  15 

Fibrin 210 

Albumen 65  09 

Coloring  matter 133  00 

Crystallizablefat 2-43 

Fluid  fat 1  31 

Extractive  matter    1  70 

Albumen,  in  combination  with  soda 1  26 

Chlorides  of  sodium  and  potassium  ;  carbonates,  phosphates, 

and  sulphates  of  potash  and  soda 8-37 

Carbonates  of  lime  and  magnesia  ;  phosphates  of  lime,  mag- 
nesia, and  iron;  peroxide  of  iron 4  oO 


100000 


In  a  healthy  and  normal  condition  of  the  human  system  we  find 
always  the  existence  of  a  relationship  between  the  requirements 
and  material  of  supply  which  should,  and  which  does,  afford  proper 
tissue  ;  where,  then,  such  conditions  exist,  the  teeth,  caeteris  paribus, 
are  perfectly  formed,  and,  as  constitutional  relations  are  concerned, 
are  healthily  preserved. 

In  the  study  of  the  pathological  conditions  of  these  organs,  we 
are  to  discover,  if  possible,  wherein  the  harmony  of  demand  and 
supply  is  or  has  been  interfered  with  ;  and  that  we  may  look  at  the 
subject  from  the  most  comprehensive  standpoint,  we  must  study 
not  only  hereditary  complications  which  may  exist,  but  are  to 
understand  as  well  the  direct  relations  of  the  developing  organs. 
This  brings  us  to  the  subject  of  nutrition  proper.  In  this  connection, 
I  know  of  no  one  who  has  given  a  more  exhaustive  attention  to  the 
subject  than  the  late  James  Paul,  M.D  ;  and  I  recognize  that  I 
could  not  afford  the  subject  better  expression  than  by  embodying 
the  substance  of  a  paper  read  by  that  gentleman  before  the  Medical 
Society  of  Mercer,  N.  J.  The  views  cannot  receive  a  too  careful  study. 

"The  subject,"  says  Dr.  Paul,  "is,  not  only  in  a  physiological 
point  of  view,  one  of  interest,  but  in  its  application  to  the  preserva- 
tion of  health — the  tendency  to  improve  the  general  condition  and 
physical  constitution  of  the  human  family  inhabiting  this  great  con- 
tinent— a  continent  abounding,  as  it  does,  in  all  the  productions 
which  a  bountiful  Creator  in  his  beneficence  bestows  on  man — 
cannot  be  otherwise  than  of  great  and  paramount  importance. 

"  At  a  period  now  somewhat  remote,  the  celebrated  naturalist 
BufFon,  alluding  to  the  animals  of  this  continent,  advanced  the  fol- 
lowing opinions: 


230  ORAL   DISEASES  AND  SURGERY. 

"  1.  That  the  animals  common  both  to  the  Old  and  the  Xevv  World 
are  smaller  in  the  latter. 

"  2.  That  those  belonging  to  the  New  are  on  a  smaller  scale. 

"3  That  those  which  have  been  domesticated  in  both  have  de- 
generated in  America. 

"4    That,  on  the  whole,  it  exhibits  fewer  species. 

"These  opinions  Mr.  Jefferson,  in  his  'Notes  on  Virginia,'  under- 
took, and,  it  is  generally  considered,  successfully,  to  controvert ;  yet, 
however  repugnant  to  the  general  idea  the  opinion  as  to  the  tend- 
ency of  those  animals  which  have  been  domesticated  in  America 
from  other  countries  to  degenerate,  it  is  an  undeniable  and  much-to- 
be-regretted  fact  that  the  human  family,  and  more  particularly  the 
female  portion  of  that  family,  have  declined  in  the  vigor  and  strength 
of  their  physical  constitution. 

"  I  wish  not  to  be  misunderstood  :  I  say  it  is  a  melancholy  fact, 
too  well  known  to  the  observant  physiologist,  that  increase  of 
strength  and  development  of  frame  have  not  been  attained  by  the 
intermarrying  of  members  of  the  human  family  of  different  nations 
on  tiiis  continent;  but  the  reverse  is  too  observable ;  the  physical 
frame  of  the  female  sex  has  degenerated, — calling  loudly  for  the  aid 
of  science  to  arrest  an  evil  of  so  much  magnitude. 

"  Let  us  for  a  moment  contemplate  the  female  form,  as  seen  on 
this  broad  continent.  In  no  country  in  the  world  are  children  more 
fair  and  beautiful ;  and  as  the  young  girl  grows  up  to  womanhood, 
we  see  in  her  a  full  realization  of  that  being  forming  in  the  hands  of 
Divinity,  portrayed  by  the  poet,  as  seen  by  Adam  in  his  dream  : 

"  •  Under  his  forming  hands  a  creature  grew, 
Manlike,  but  diflerent  sex;  so  lovely  fair 
That  what  seemed  fair  in  all  the  world,  seemed  now 
Mean,  or  in  her  summed  up,  in  her  contained, 
And  in  her  looks.' 

"We  see  this  young  and  lovely  being — the  forehead  well  de- 
veloped, the  countenance,  rather  elongated,  I'elieved  of  the  harsher 
outline  of  some  of  the  European  nations,  with  fragile  form  and 
small  yet  well-developed  bust — flitting  for  a  few  short  years  among 
us,  and  then — yes,  then — there  comes  a  change.  Ere  five-and- 
tvventy  summers  pass,  thts  flower  begins  to  fade — the  rounded  form 
shrinks — the  bloom  of  health  decays;  and  if  she  escapes  the  fell 
destroying  angel's  deathlike  grasp,  a  wreck  of  former  self  remains. 

"Why  should  this  be  so?     The  robust  of  other  countries  come 


THE   TEETH  AND    THEIR   DISEASES.  281 

to  this  continent.  They  live  in  comfort;  their  food  is  excellent  in 
quality;  their  progeny  is  like  themselves;  but  even  now,  in  the 
very  first  generation,  does  the  degenerating  process  make  itself 
manifest, — the  teeth  begin  to  decay;  and  girls,  while  yet  children, 
have  to  visit  the  dentist  to  have  them  cleansed,  scraped,  and 
plugged. 

"Now,  this  brings  us  at  once  to  the  head  and  front  of  our  subject ; 
and  if  we  can  point  out  the  first  cause  of  this  decay  of  what  should 
be  as  strong  as  adamant,  it  may  be  the  means  of  helping  us  in  our 
investigation.  That  there  is  something  radically  wi'ong  in  our  sys- 
tem of  rearing  the  young,  to  which  this  misfortune  is  in  a  great 
measure  owing,  I  am  free  to  confess  is  my  firm  opinion.  I  would 
indeed  it  were  in  my  power,  in  pointing  out  the  evil,  to  be  as  suc- 
cessful in  detailing  the  cause,  that  we  may  apply  the  remedy.  Still, 
although  perhaps  unable  to  accomplish  all  I  wish,  my  observations 
may  not  be  without  their  weight,  and  induce  others,  more  observant, 
more  scientific,  and  more  competent  to  the  task,  to  follow  up  an 
investigation  so  fraught  with  advantage  to  our  fellow-beings. 

"It  is  certainly  to  be  deplored  that  the  females  of  this  continent, 
descendants  of  European  parents,  should  be  so  much  afflicted  with 
caries  of  the  teeth,  the  decay  of  parts  formed  of  substances  which 
enter  into  the  composition  of  some  of  our  hardest  minerals, — marble, 
bone-earth,  and  fluor-spar ;  and  this  decay  unfortunately  occurs  in 
early  life, — in  girls  yet  at  school ;  and  many  a  young  woman,  ere 
she  has  attained  a  marriageable  age,  has  had  to  replace  the  natural 
with  the  unnatural  though  more  enduring  enamel  of  the  artist's 
formation.  This  ought  not  to  be:  God  made  all  mankind  alike;  in 
no  portion  of  the  earth  are  nations  found  who  lose  their  hands,  or 
feet,  or  tongue,  or  eyes  ;  and  there  can  be  no  cause  why  the  inhabit- 
ants of  this  land  should  lose  their  teeth.  It  is  not  so  in  the  olden 
countries  from  whence  the  progenitors  of  the  present  race  have 
come ;  nor  is  it  so  in  the  West  India  islands,  which  may  almost  be 
considered  as  part  of  this  great  continent.  So  excellent  is  the  struc- 
ture of  the  teeth  of  savage  nations,  that  some  tribes  in  Africa,  I 
think  the  Mocoes  and  Mandingoes,  file  all  the  front  teeth,  so  that 
they  shall  be  separated  and  form  sharp  points,  the  better  to  tear 
the  uncooked  animal  food. 

"One  cause  of  this  affliction  is,  in  the  minds  of  many,  attributed 
to  the  great  and  sudden  changes  of  temperature  experienced  on  this 
continent,  —  the  thermometer  rising  and  falling  twenty,  thirty,  and 
even  forty  degrees  in  twelve  hours.     But  if  attributable  to  these 


232  ORAL  DISEASES  AND  SURGERY. 

sudden  changes,  we  know  that  sudden  expansion  by  means  of  heat,  or 
sudden  contraction  by  means  of  cold,  causes  the  particles  of  which 
bodies  are  composed  to  tear  themselves  asunder;  consequently,  to 
crack,  break,  and  fall  in  pieces.  But  this  is  not  the  case  with  the 
teeth  of  our  females;  a  caries  or  decay  commences  most  generally 
in  the  side  of  the  tooth,  extending  to  the  enamel,  which  is  some- 
times involved  in  the  destruction;  at  other  times  it  is  left  a  crust 
or  shell  to  snap  and  break  off  in  small  pieces,  when  unable  to  resist 
the  pressure  of  whatever  may  be  placed  against  it ;  besides,  the 
teeth  are  for  the  most  part  sheltered  from  these  sudden  changes, 
and  kept  at  a  temperature  nearly  amounting  to  blood-heat  at  all 
seasons.  I  do  not  think  we  can  place  the  general  destruction  of  the 
teeth,  and  consequent  affliction  of  the  females  of  America,  to  this 
cause.  I  fear  we  must  rather  look  for  it  to  constitutional  weakness, 
and  this  constitutional  weakness  to  a  deficiency  of  the  inorganic  or 
earthy  constituents  being  taken  into  the  system,  more  particularly 
at  an  early  period  of  life.* 

"If  I  am  correct  in  this  opinion, — and  reason,  philosophy,  and  a 
thorough  examination  of  physiological  facts  in  both  the  animal  and 
vegetable  economy,  tend  far  to  bear  out  these  views, — then  if  we 
would  try  and  correct  this  lamentable  state  of  things,  let  us  com- 
mence at  the  very  beginning,  and  make  ourselves  acquainted  by 
examining  the  structure  and  composition  of  the  teeth,  and  then  we 
shall  be  more  able  to  understand  what  is  required  to  aid  nature  in 
their  formation  and  consequent  preservation. 

"  First,  then,  let  us  make  ourselves  acquainted  with  the  structure 
and  composition  of  the  teeth.  The  teeth  are  nearly  allied  to  bone 
in  structure ;  both  having  earthy  deposits,  intermixed  with  fibres 
and  cells  of  gelatin,  which,  by  consolidation,  gives  form  and  strength, 
in  the  case  of  bone,  to  bear  the  weight  of  the  various  parts  and 
afford  protection  to  the  diff"erent  organs  of  the  body;  and  in  the  case 
of  teeth,  to  cut  and  grind  the  food  required  for  the  formation,  sup- 
port, and  reparation  of  its  various  parts. 

"Now,  teeth  are  compo.sed  of  three  different  substances,  and 
these  three  are  disposed  according  to  the  purposes  required  of  them  ; 
they  are  cementum  or  criista  jMrosa,  dentine  (known  as  ivory  in  the 
tusk  of  the  elephant),  and  enamel.    The  cementum  or  crusta  petrosa 


*  Experiments  have  demonstrated  that  teeth  may  be  changed  instantly 
from  iced  to  boiling  water  without  cracking  the  enamel.  Injury  to  the  teeth 
from  thermal  changes  would  arise  rather  from  irritation  inflicted  on  the  pulp. 


THE   TEETH  AND    THEIB  DISEASES.  233 

corresponds  in  all  essential  particulars  with  bone,  possessing  its  char- 
acteristic lacunae  or  small  cavities,  and  being  traversed  by  vascular 
medullary  canals,  whenever  it  occurs  of  sufficient  thickness ;  it  is 
the  first  covering  of  the  young  tooth,  and  may  be  said  to  invest  the 
fang  of  the  tooth  which  enters  the  alveolar  process  of  the  jaw.  The 
dentine,  or  ivory,  consists  of  a  firmer  substance,  in  which  inorganic 
or  mineral  matter  predominates,  though  to  a  less  degree  than  in 
enamel.  It  is  traversed  by  a  vast  number  of  very  fine,  cylindrical, 
branching,  wavy  tubuli,  which  commence  at  the  pulp  cavity  and 
radiate  toward  the  surface.  The  diameters  of  these  tubuli,  at  their 
largest  part,  average  about  1-10, 000th  of  an  inch  ;  their  smallest  are 
immeasurably  fine;  so  much  so,  that  they  cannot  possibly  receive 
blood,  but  it  is  surmised  that,  like  the  canaliculi  of  bone,  they  imbibe 
fluid  from  the  vascular  lining  of  the  pulp  cavity,  which  aids  in  the 
nutrition  of  the  tooth.  The  enamel  is  composed  of  solid  prisms  of 
fibres,  about  the  l-5600th  of  an  inch  in  diameter,  arranged  side  by 
side,  and  closely  adherent  to  each  other ;  their  length  corresponds 
with  the  thickness  of  the  layer  which  they  form  ;  and  the  two  sur- 
faces of  this  layer  present  the  ends  of  the  prism,  which  are  usually 
more  or  less  hexagonal.  In  the  perfect  state,  the  enamel  contains 
but  an  extremely  minute  quantity  of  animal  matter.  In  the  centre 
of  the  tooth  is  the  soft  pulp  cavity,  which  affords  a  bed  for  the 
blood-vessels  and  nerves  which  supply  it  with  life  and  sensibility. 

"i  shall  not  enter  more  minutely  into  the  structure  of  the  teeth, 
but  may  briefly  state  that,  like  all  other  structures  of  the  animal 
body,  the  component  parts  are  derived  and  deposited  from  the 
blood,  by  that  mysterious  and  incomprehensible  power  that  selects 
and  deposits  the  necessary  constituents  in  the  formation  of  the 
several  portions,  according  to  the  use  required. 

"Now,  in  the  composition  of  the  teeth,  we  have  first  the  division 
into  organic  and  inorganic  or  earthy  matter;  and  we  find  that  the 
several  substances  which  enter  into  the  structure  of  the  teeth  differ 
chiefly  as  to  the  earthy  matter  contained  in  each. 

"Chemical  analysis  of  the  incisors,  or  front  teeth  of  man,  shows 
that  they  contain  in  one  hundred  parts  of  each,  as  follows: 

Cementum.      Dentine.        Enamel. 

Organic  matter 29  27         28-70  3  59 

Earthy  matter 7073         7130         96-41 


100-  100-  100- 

"  These  proportions  will  occasionally  differ  ;  in  some  individuals 


234  ORAL  DISEASES  AND  SURGERY. 

the  organic  constituents  having  less  than  here  stated,  amounting  in 
the  dentine  only  to  21.  The  analysis  of  bone,  however,  gives  a 
much  larger  proportion, — viz. : 

Organic  matter 32-56 

Earthy  matter  67-44 

100- 

"Let  us  now  take  a  more  complete  analysis,  showing  what  earthy 
constituents  enter  into  their  composition.  Analysis  of  the  molar  or 
grinding  teeth  of  man,  and  of  the  bones  of  the  arm  and  leg  of  a 
man  of  forty,  shows  the  following  proportions: 

Dentine.  Enamel.  Bone. 

Inorganic  matter: 

Phosphate  of  lime,  with  traces  of  fluate  of  lime  66  72  89  82  54-61 

Carbonate  of  lime 3  36  4-37  9-41 

Phosphate  of  magnesia I'OS  134  107 

Salts,  etc -83  -88  2-85 

Organic  matter 28  01  3-59  32-56 

100-  100-  100. 

"  Thus  we  see  the  very  great  proportion  of  certain  earths  that 
enter  into  the  structure  of  the  teeth  and  the  bones  of  man,  the  chief 
substance  being  the  phosphate  of  lime,  familiarly  known  as  bone- 
earth.  We  find,  too,  that  whereas  in  ordinary  bone  the  phosphate 
of  lime  constitutes  only  54  parts  in  100,  in  the  enamel  of  the  teeth 
it  is  nearly  90  parts  in  100;  while  the  carbonate  of  lime  in  bone 
amounts  to  9-41,  in  the  enamel  of  teeth  it  is  only  4'3'7, — the  enamel 
being  literally  almost  a  mineral  in  substance,  having  only  3.59  parts 
of  animal  matter  in  100. 

^  "Thus  the  teeth,  to  be  strong  and  durable,  require  a  large 
quantity  of  earthy  ingredients,  particularly  lime,  to  enter  into  their 
composition.  Let  us  inquire  whence  it  is  derived  ;  and  for  this 
we  must  examine  the  blood. 

"  To  allow  of  such  deposits  from  the  blood,  it  is  first  necessary 
that  they  should  be  held  in  solution  in  that  fluid.  The  blood  circu- 
lates to  every  portion  of  the  body  by  the  action  of  the  heart,  which 
forces  a  certain  quantity — say  two  ounces  at  every  contraction — 
into  the  aorta  or  great  canal  leading  from  the  left  ventricle.  The 
aorta  divides  and  subdivides  into  innumerable  branches,  which  are 
made  to  ramify  to  every  part  of  the  body,  until  the  extreme  branches 
end  in  capillary  tubes  or  vessels,  the  calibre  of  which  is  so  small  as 


\ 


THE   TEETH  AND    THEIR  DISEASES.  235 

not  to  allow  the  red  globules  or  corpuscles  of  the  blood  to  enter 
them,  but  which  allows  the  serous  portion  to  traverse  every  part  of 
the  organized  structure,  holding  in  solution  all  those  constituents 
necessary  and  requisite  for  the  formation  and  reparation  of  its  several 
parts. 

"  In  the  serous  portion  of  the  blood,  then,  we  find  contained 
the  constituents  required  for  the  composition  of  bone  and  teeth, — 
analysis  of  1000  parts  of  healthy  human  blood  giving,  according  to 
M.  Lecanu,  the  following  proportions: 

Water 780-15  78558 

Fibrin 2  10  3-57 

Albumen 6509  69  41 

Coloring  matter 133-00  119-63 

Crystallizable  fat 2-43  4-30 

Fluid  fat 131  227 

Extractive  matter,  uncertain 1-79  1-92 

Albumen  in  combination  with  soda 1-26  201 

Chlorides  of  sodium  and  potassium  ;  carbonates, 

phosphates,  and  sulphates  of  potash  and  soda...  837  7-30 
Carbonates  of  lime  and  magnesia;  phosphates  of 

lime,  magnesia,  and  iron;  peroxide  of  iron....  2-10  1  42 

Loss 2-40  2-50 

1000-  1000- 

"We  see  by  this  table,  if  we  subtract  or  take  away  the  proportion 
of  water,  amounting  to  tSO  parts,  and  the  coloring  matter,  amounting 
to  133,  we  sliall  leave  scarcely  90  parts  of  organic  and  earthy  ma- 
terial, the  salts  and  earths  forming  upwards  of  a  10th, — the  salts 
being  in  proportion  to  the  earths  as  4  to  I. 

"  Having  then  shown  the  constituent  portions  of  the  bones  and 
teeth  to  be  in  the  blood,  the  next  consideration  is,  whence  are  they 
derived  ? 

"Before  entering  on  this  subject  further,  let  us  for  a  moment  take 
a  broader  and  more  comprehensive  view  of  what  must  be  most 
interesting  to  mothers,  and  of  great  consequence  to  the  well-being 
of  the  infant  generation,  in  a  short  time,  in  a  very  few  years,  to 
become  in  their  turn  the  mothers  and  fathers  of  another  generation. 

"The  question  then  presents  itself,  what  is  the  nourishment  or 
food  best  adapted  and  necessary  to  the  wants  of  an  infant,  that  the 
foundation  may  be  laid  for  a  strong  frame  and  vigorous  constitution  ? 
For  here,  we  must  recollect,  is  the  starting-point  in  by  far  the  ma- 
jority of  instances.     We  know  that  in  some  cases  disease  is  hered- 


236  ORAL  DISEASES  AND   SURGERY. 

itary, that  the  offspring  unfortunately  inherits  from  the  parents 

constitutional  defects  ;  but  we  also  know  that  more  misery,  suffer- 
ing, and  constitutional  derangement  are  entailed  on  children  by 
want  of  care  and  improper  food  in  the  first  years  of  life,  by 
which  their  hopes  of  health  are  blasted,  and  they  are  doomed  to 
struge'le  through  a  weary  life,  to  be  hurried  at  last  into  a  premature 
grave. 

"Now,  that  the  frame — that  is,  the  bones,  muscles,  and  other 
portions — of  the  infant  may  be  fully  developed,  it  is  necessary  that 
it  should  be  supplied  with  nourishment  containing  all  the  constitu- 
ents required  for  this  important  undertaking.  And  this  nourish- 
ment, by  the  all-wise  ordering  of  Providence,  is  contained  in  the 
milk  secreted  from  the  mother's  bosom. 

"  The  infant  is  entirely  dependent  on  the  nourishment  derived 
from  its  mother,  and  nature  has  wisely  ordained  that  the  secretion 
from  the  mother  is  its  very  best  food  ;  for  we  find  in  the  composi- 
tion of  milk — that  is,  healthy  milk,  derived  from  healthy  blood — 
all  those  ingredients  we  have  hitherto  traced  as  requisite  in  the 
formation  of  the  bones  and  teeth,  and  not  only  these,  but  every  con- 
stituent required  for  the  life  and  growth  of  the  individual ;  milk 
containing  the  albuminous,  saccharine,  oleaginous,  saline,  and  earthy 
compounds  requisite  and  necessary  for  the  health,  strength,  and  de- 
velopment of  the  infant  child. 

"An  analysis  of  cow's  milk  gives  the  following  proportions  of  the 
various  constituents ;  that  of  human  milk  is  not  so  elaborate,  but 
contains  the  average  of  observations  taken  at  fourteen  different  times 
from  the  same  individual,  by  Simon. 

Cow's  Milk,  by  M.  Haidlen. 

Water 87300 

Butter 3000 

Casein 4820 

Milk  sugar 43-90 

Phosphate  of  lime 2-31 

Phosphate  of  magnesia -42 

Phosphate  of  iron ■. -07 

Chloride  of  potassium 1-44 

Chloride  of  sodium -24 

Soda  in  connection  with  casein -42 

1000. 


THE   TEETH  AND    THEIR  DISEASES.  237 


Woman's  Milk,  by  Simon. 

Water 883-6 

Butter 25o 

Casein 34  3 

Milk  sugar  and  extractive  matter 482 

Fixed  salts 2  3 


1000. 


Maximum  of  Minimum  of 

14  observations.  1-t  observations. 

Butter. 54  0  .          80 

Casein 45-2  10-6 

Sugar  and  extractive  matter 62-4  39-2 

Salts 2-7  1-6 

"Now,  although  these  amounts  will  no  doubt  vary,  under  every 
variety  of  circumstances,  according  to  the  health,  exercise,  pasaions, 
and  food  of  the  mother,  yet  they  show  that  healthy  milk  contains 
all  the  requisites  for  the  nourishment  of  the  infant;  but  then  it  must 
be  healthy  milk,  secreted  from  healthy  blood,  and  that  blood  must 
derive  these  ingredients  from  the  food  consumed. 

"  Cow's  milk  differs  from  that  of  woman  in  the  proportions  of 
some  of  the  constituents:  it  abounds  more  in  butter,  but  particularly 
in  casein,  or  cheese;  and,  on  the  other  hand,  human  milk  abounds 
niore  in  the  saccharine  principle,  or  sugar  of  milk.  Now,  this  points 
out  a  circumstance  from  which  great  benefit  may  be  derived.  It  is 
of  very  frequent  occurrence  that  infants  are  deprived  of  the  natural 
nourishment  of  the  mother,  and  diverse  opinions  are  given  relative 
to  the  food  of  infants  by  persons  who  really  know  very  little  about 
the  matter  ;  one  recommends  a  milk  diet,  another  that  the  infant 
must  be  fed  on  starch  and  sugar. 

"  Now,  to  enable  the  infant  to  receive  a  nourishment  in  every  re- 
spect similar  to  the  mother,  the  knowledge  of  the  various  propor- 
tions which  we  obtain  by  chemical  analysis  enables  us  to  rectify 
and  produce  milk  very  analogous  to  human  milk  from  that  of  the 
cow,  by  diluting  it  with  water  in  the  proportion  of  about  half  as 
much  again ;  that  is,  to  a  pint  of  milk  should  be  added  half  a  pint  of 
water  that  has  been  boiled,  which  will  reduce  the  cheese  principle  to 
the  proper  proportion ;  add  a  small  portion  of  cream  to  restore  the 
proportion  of  butter,  and  then  add  sugar  until  the  whole  is  dis- 
tinctly sweetened,  and  we  have  a  compound  in  every  respect  similar 
to  the  milk  from  the  human  breast. 


238  ORAL  DISEASES  AND  SURGERY. 

"To  understand  the  subject  of  nutrition,  let  us  remember  that 
food  should,  or  must,  embody  two  great  principles  :  one  to  nourish, 
the  other  to  give  heat  to  the  body.  And  food,  when  consumed,  is 
applied  to  one  or  the  other  of  these  purposes.  Now,  in  the  process 
of  digestion,  the  constituents  of  the  food  are  separated,  and  arranged 
in  three  classes: 

"  1st.  All  that  portion  derived  from  animal  food,  eggs,  the  curd 
of  milk,  the  gluten  or  adhesive  portion  of  wheat  and  other  grain, 
and  whatever  in  animal  or  vegetable  food  can  be  rendered  into  albu- 
men— of  which  the  best  example  that  can  be  offered  in  illustration  is 
the  white  of  egg,  which  is  in  reality  nearly  pure  albumen — and  the 
principle  is  therefore  called  albuminous. 

"  2d.  All  that  portion  of  the  food  derived  from  vegetables,  starch, 
sugar,  etc.  that  can  be  converted  into  sugar  in  the  process  of  diges- 
tion.    This  principle  is  therefore  called  saccharine. 

"  3d.  All  the  fat,  butter,  oil,  etc.  which,  when  deprived  of  the 
other  substances,  is  left  in  the  state  of  oil,  and  therefore  called  ole- 
aginous. 

"Now,  of  these  three  the  albuminous  is  the  nutrient,  and  the 
saccharine  and  oleaginous  are  the  calorifacient,  or  heat-giving ;  and 
chemical  analysis  shows  that  they  vary  in  composition. 

ALBUMINOUS.  OLEAGINOUS. 

Eggs.  Wlieat.       Mutton  fat. 

Carbon 55000  55  01         78-996 

Hydrogen 7-073  7-23         11-700 

Nitrogen 15  920  15  92 

Oxygen         -|  9  304 

Sulphur         I 22-007  21-84 

Phosphorus  )  

SACCHARINE. 

Starch,  Sugar  Sugar        Cane 

arrow-root,  from  starch,  of  milk,    sugar. 

Carbon 44  40        37  29  40  00     42  301 

Hydrogen 6-18  6  84  6-61       6-384 

Oxygen 49-42         55  87  5293     51-315 

"It  will  be  observed  that  the  albuminous  or  nutrient  differs  from 
the  saccharine  and  oleaginous,  in  containing  nitrogen,  and  sulphur 
and  phosphorus,  with  carbon,  hydrogen,  and  oxygen,  while  the  latter 
contains  only  carbon,  hydrogen,  and  oxygen, — nitrogen  being  re- 
quired in  those  compounds  which  give  strength  and  formation  to 
the  frame. 


THE   TEETH  AND    THEIR  DISEASES.  239 

"  Now,  the  albuminous  or  nutritive,  being  that  portion  which 
affords  nourishment  to  the  body,  contains  those  constituents  re- 
quired in  the  first  place  for  the  formation  and  giving  strength  to  the 
.different  portions  of  the  body,  and,  when  fully  developed,  of  repair- 
ing the  general  waste  continually  going  on  in  the  system,  whether 
from  the  usual  wear  and  tear,  fractured  bones,  or  the  ravages  of 
disease.  And  the  saccharine  and  oleaginous — the  calorifacient  or 
heat-making — to  keep  up  a  continual  supply  of  fuel,  as  it  were,  that 
the  bodv  may  be  kept  of  a  regular  and  proper  temperature  ;  for  all 
are  no  doubt  aware  that  there  is  a  continual  supply  of  carbon,  or, 
in  more  simple  language,  of  charcoal,  required  to  keep  up  the  natural 
temperature  of  the  body;  and  what  is  not  required  for  immediate 
use  is  stored  away  in  the  form  of  fat,  to  be  called  into  action  as 
occasion  requires. 

"  We  have  seen  in  the  analysis  of  milk  that  that  fluid  contains 
butter,  cheese,  and  sugar;  consequently  we  can  understand  how  an 
infant  can  thrive  so  w^ell  upon  it, — the  cheese  or  casein*  of  the 
milk  containing  the  nitrogenized  or  nutrient  principle,  which,  to- 
gether with  the  earths  and  salts  contained  in  the  milk,  goes  to  form 
the  bones,  muscles,  and  the  different  tissues  of  the  bod}', — the  sugar, 
which,  we  have  seen  by  the  analysis,  contains  a  large  quantity  of 
carbon  in  its  composition,  going  to  keep  up  the  temperature  of  the 
infant,  while  the  butter,  in  the  nature  of  fat,  is  stored  away  in  a 
healthy  infant,  filling  up  every  vacant  interstice,  causing  a  round- 
ness and  plumpness,  the  pride  and  joy  of  the  happy  parent. 

"  Now,  let  us  mark  the  difference  of  the  babe  that  has  been  denied 
a  milk  diet,  and  is  doomed  by  ignorance  to  be  fed  on  starch  and 
sugar.  We  will  recollect  that  these  two  substances  are  composed 
of  carbon,  hydrogen,  and  oxygen  only.  By  a  process  of  digestion 
which  I  need  not  here  enter  into,  such  food  is  converted  into  sugar, 
the  carbon  of  which  becomes  the  fuel  by  which  the  temperature  of 
the  body  is  kept  up  ;  there  being  no  principle  in  the  food  to  give 
albumen,  there  is  nothing  taken  into  the  stomach  upon  which  the 


*  Carbon 

Hydrogen. 
Nitroscen.. 


Oxygen 
Sulphur 


} 


Anal.vsis  of 

Alb- 

iVinous  substances  found 

casein  from 

in 

whej 

after  coagulation 

fresh  milk. 

wi 

tb  an  acid. 

54-82.5 

54-06 

7-153 

7-15 

15-628 

15-89 
21-73 

22.394 

0-86 

240  ORAL  DISEASES  AND   SURGERY. 

gastric  fluid  can  expend  its  solvent  powers;  the  infant  is,  therefore, 
much  troubled  with  acid  eructations,  and  the  stomach  becomes  weak 
and  irritable.  The  want  of  the  nutritive  constituent  of  the  food, 
and  the  earths  and  salts,  etc.  necessary  and  essential  for  the  forma- 
tion of  the  bones  and  teeth,  show  a  lamentable  deficiency  in  the 
child's  development ;  and  there  being  no  fatty  matter  to  be  laid  up, 
the  body  is  emaciated,  the  countenance  is  ghastly,  the  flesh  and  in- 
teguments hang  soft  and  flabby  over  the  bones;  no  absolute  disease 
can  be  detected;  the  child  is  ravenous  and  hungry,  and  the  unfortu- 
nate babe  descends  to  the  tomb  a  spectre  and  an  object  of  the  most 
pitiful  description.  This  is  no  fancy  sketch,  but  one  too  often  met 
with  in  the  ordinary  walks  of  professional  life.  And  why  is  it  so  ? 
Simply  because  the  composition  of  the  human  frame,  the  component 
parts  of  our  food  requisite  to  produce  that  frame,  and  the  process  of 
digestion  and  nutrition,  are  so  little  understood. 

"We  now  advance  from  infancy  to  childhood  ;  and  this  is  a  period 
when  the  greatest  attention  is  required  in  supplying  nutriment  to 
aid  nature  in  the  great  work  of  developing  the  body.  The  child  is 
now  deprived  of  the  maternal  secretion,  and  dependent  on  food  pre- 
pared for  its  use  by  the  hand  of  man, — perhaps  living  in  a  city,  and 
deprived  of  pure  and  wholesome  milk  from  the  cow.  And  we  know 
there  is  a  vast  disproportion  in  the  quality  of  milk  when  the  cow  is 
country-fed  on  the  natural  productions  of  the  farm,  and  when  city- 
fed  on  slops  and  grain,  the  refuse  of  the  brewery. 

"  It  is  at  this  age  that  the  great  proportion  of  bony  substance  is 
deposited;  those  of  the  extremities  are  lengthened,  become  more 
compact  and  stronger,  and  the  substance  of  the  teeth  is  deposited 
in  the  cells  of  gelatinous  tissue.  How  necessary  is  it,  then,  that 
this  subject  should  receive  the  utmost  attention  of  parents!  It  has 
hitherto  been  too  much  the  custom  to  leave  all  this,  as  belonging 
entirel}'^  to  nature,  as  a  thing  we  had  nothing  to  do  with.  We  have 
been  too  much  in  the  habit  of  considering  that  nature  furnished  her 
own  materials,  and  man  had  nothing  to  do  with  her  operation.  The 
potter  cannot  fashion  the  bowl  without  the  clay,  neither  can  bone 
be  formed  without  earth  :  nature  must  be  supplied  with  the  material, 
which,  although  offered  in  the  most  incongruous  forms,  she  has  the 
power  of  decomposing,  selecting  from,  and  supplying  for  the  various 
purposes  required :  one  portion,  as  we  have  already  stated,  to  act  as 
fuel  in  keeping  up  the  temperatm-e  ;  another  portion  she  selects  to 
add  to  the  flesh,  the  muscle,  skin,  and  different  tissues;  and  the 
earths  which   are   held   in   solution    she  carries  away  by  vessels 


THE   TEETH  AND    THEIR  DISEASES.  241 

adapted  for  that  purpose,  and  deposits  them  atom  by  atom,  until 
they  are  so  compressed,  so  strongly  compacted  together,  as  to 
become  what  we  call  solid  bone, — and  all  this  so  wonderfully 
wrought  that,  as  we  have  seen,  small  tubes  are  left  in  the  hard, 
stony  formations  both  of  the  bones  and  of  the  teeth,  that  nourish- 
ment may  be  supplied  them,  holding  in  solution  the  material  of 
which  they  are  composed,  that  the  natural  waste  and  decay  may  be 
replaced  and  injuries  repaired. 

"It  is  to  this  nutrition,  and  to  the  earthy  matter  of  which  the 
bones  and  teeth  are  composed,  a  deficiency  of  which  is  attended 
with  results  so  deplorable,  that  I  particularly  wish  to  call  attention. 

"  To  what  can  we  attribute  the  calamity  which  too  often  befalls 
the  young?  I  allude  to  distorted  spines,  where  the  bones  com- 
posing the  spine,  instead  of  forming  a  column,  allowing  the  body 
to  be  erect  and  dignified,  are  zigzag  in  their  course,  causing  one 
shoulder  to  bulge  out,  and  the  opposite  side  to  bend  or  double  upon 
itself.  This  deformity  has  been  long  understood  to  arise  from  a 
deficiency  of  lime  in  the  composition  of  the  bones  of  the  vertebrae, 
allowing  them  to  fall,  press  upon,  and  injure  each  other,  destroying 
the  beauty  of  the  fabric  and  the  health  and  comfort  of  the  indi- 
vidual. 

"  Now  let  us  take  a  glance  at  the  inhabitants  of  two  countries, 
natives  of  which  are  no  strangers  on  this  continent.  I  take  them 
as  examples,  because  the  food  of  the  common  peojyle  of  those  coun- 
tries is  well  known  to  be  of  the  most  common  kind.  I  allude  to 
natives  of  Scotland  and  Ireland, — the  principal  food  of  one  being 
oatmeal,  and  of  the  other  ^o^a^oes.  We  have  heard  a  great  deal  of 
the  famishing  poor  of  those  countries,  and  particularly  of  the  latter, 
of  the  misery  and  wretchedness  seen  in  every  hovel  ;  and  there 
cannot  be  a  doubt  that  famine  walked  through  the  land  when  the 
blight  and  rot  despoiled  them  of  their  potato  crop,  on  which  for  so 
long  a  period  they  depended  as  the  great  article  of  food.  Now, 
allowing  all  this, — allowing,  in  the  best  seasons,  the  chief  article  of 
subsistence  has  been  potatoes  for  breakfast,  dinner,  and  supper ; 
— glad  indeed  many  of  them  to  get  a  little  animal  food  once  a  week 
to  dinner,  or  even  far  more  seldom, — I  now  ask,  what  number,  in 
the  thousands  of  emigrants  from  that  country  who  yearly  arrive  at 
our  ports,  are  there  that  show  a  constitution  weak,  fragile,  and 
wanting  in  physical  strength  ?  Many,  no  doubt,  arrive  worn  down 
by  disease  and  suffering,  and  in  the  last  stage  of  debility;  but  let 
them  recover  from  that  state,  and  the  robust  frame  and  healthy  con- 

16 


242  ORAL  DISEASES  AND   SURGERY. 

stitution  will  be  again  developed  ;  the  bones  are  strong,  the  teeth 
undecayed,  and  the  muscular  energy  only  wanting  opportunity  to 
display  itself; — in  fact,  when  we  wish  to  denote  strength  in  woman, 
we  use  the  familiar  phrase,  '  strong  as  an  Irishwoman,'  and  all 
this  from  being  reared  on  potatoes*  But  then,  if  we  examine  the 
analysis  of  the  potatoes,  we  shall  find  contained  in  100  parts  of  dry 
potatoes, — 

Carbon 41  1 

Hydrogen 5-8 

Nitrogen  )                                                                4g.j 

Oxygen     ) 

Ashes 50 

"Here  we  see  that  potatoes  not  only  contain  the  nutrient  but  the 
earthy  constituents. 

"  But  we  have  a  stronger  and  more  healthy  race  yet,  from  Scot- 
land and  the  north  of  Ireland,  who  are  generally  descendants  of  the 
Scotch,  and  continue,  in  a  great  measure,  the  same  means  in  rearing 
the  young.  Now,  a  principal — I  will  not  say  the  principal — food  of 
the  youth  of  Scotland,  high  and  low,  rich  and  poor,  except  in  the 
larger  cities,  among  those  who  class  themselves  as  more  refined  and 
more  civilized,  but  who  number  few  in  proportion,  consists,  for 
breakfast,  at  least,  of  oatmeal, — that  is,  porridge  and  milk ;  and 
milk,  potatoes,  and  wheaten,  oaten,  or  pease  bread,  or  bannocks,  at 
other  times  of  the  day.  Animal  food  among  the  poor  is  a  rarity,  a 
meat  dinner  on  Sunday  only  being  common.  Even  among  the  youth 
of  the  better  class,  butcher's  meat,  or  animal  food,  is  by  no  means  a 
principal  article  of  subsistence.  And  I  would  particularly  remark 
that  Scotch  oatmeal  (the  oatmeal  generally  used  throughout  Scot- 


*  According  to  a  memorial  presented  to  the  French  minister,  on  the  pro- 
portions of  nutriment  of  the  means  of  living,  by  Dr.  Glaser,  we  find  potatoes 
taking  no  mean  rank. 

NUTRITIVE    ELEMENTS. 

100  lbs.  wheat  bread  contains  30  lbs. 

"  flesh      ■     .  "  21  lbs. 

"  fresh  beans  "  80  lbs.  ^ 

"  peas  "  83  lbs.  [casein  and  starch. 

"  lentils  "  94  lbs.  J 

"  potatoes  "  25  lbs.,  albumen,  starch  and  sugar. 

'"  carrots  "  14  lbs. "» 

beets  "  8  iijg^l  albumen  with  sugar. 


THE    TEETH  AND    THEIR   DISEASES.  243 

land)  is  coarse,  and  contains  much  of  the  bran  whicli  invests  the 
oat, — containing,  as  it  does,  a  large  proportion  of  the  earthy  con- 
stituents required  for  the  production  of  bone.  Analysis  of  100  parts 
of  dried  oats  gives — 

Carbon 5-07 

Hydrogen 6-4 

Oxygen 36-7 

Nitrogen 2-2 

Ashes 4-0 

"I  may  here  casually  remark,  that  the  advantage  to  be  derived 
from  this  wholesome  food  iuis  not  escaped  the  observation  of  her 
Majesty,  Queen  Victoria,  who  appears  in  tlie  multiplicity  of  her 
public  duties  not  to  lose  sight  of  the  equally  sacred  duties  of  a 
mother  ;  and  we  hear  of  her  son,  the  heir  to  the  crown  of  Great 
Britain,  being  as  fond  of  his  oatmeal  porridge  as  the  meanest 
peasant  child  in  Scotland. 

"  I  rather  doubt  if  parents  generally  have  given  to  this  subject 
the  attention  to  which  it  is  entitled.  I  trust,  however,  that  those 
who  have  followed  me  thus  far,  may  be  impressed  with  its  irapoi*- 
tance.  We  cannot  shut  our  eyes  to  the  complaint  which  so  gen- 
erally prevails  of  decayed  teeth  ;  and  a  moment's  reflection  will  call 
to  mind  the  number  of  the  young  and  beautiful  who  are  prematurely 
hurried  to  the  tomb,  ere  yet  the  bud  has  expanded  into  the  full- 
developed  flower.  Nay,  comparing  the  two  countries,  the  statistics 
of  life  and  death  communicate  to  us  also  the  important  fact,  that 
while  the  greatest  mortality  shows  itself  in  England  in  infancy  and 
childhood,  on  this  side  the  Atlantic  it  is  found  at  a  more  mature  age. 

"  Neither  has  the  tendency  of  the  physical  organization  of  woman 
on  this  continent  to  degenerate  escaped  the  observation  of  one  of 
our  greatest  medical  philosophers  in  this  country,*  who  regards  this 
retrogression  as  a  national  calamity,  and  impresses  upon  his 
students  the  importance  of  the  subject,  and  the  propriety  of  their 
attention  in  attempting  to  arrest  it;  and  he  particularly  specifies 
the  great  object  to  be  gained  in  the  use  of  bran-bread  made  from 
unbolted  flour.     On  this  head  1  shall  have  more  to  say  hereafter. 

"With  these  observations,  let  us  now  direct  our  attention  to  what 
can  be  offered  in  remedy  of  this  evil. 

"We  have  already  stated  that  in  no  country  in  the  world  are 

*  Prof.  Samuel  Jackson,  of  the  University  of  Pennsylvania. 


244  ORAL  DISEASES  AND  SURGERY. 

children  more  beautiful  or  more  lovely — healtliy  in  complexion, 
quick,  smart,  and  intelligent — active,  sprightly,  and  playful  in  their 
disposition.  Now.  in**the  period  from  infancy  until  the  child 
becomes  mature, — let  us,  at  all  events,  say  until  thirteen  or  fourteen 
years,  and  even  to  a  more  advanced  age, — there  is  a  continued 
growth, — a  continual  deposition  of  organic  and  inorganic  or  earthy 
particles,  which  are  required  for  the  formation  of  bone,  teeth,  flesh, 
and  every  part  of  the  human  body.  I  have  shown  that  the  essential 
ingredients  for  these  several  formations  are  all  found  in  the  milk  of 
the  mother;  consequently,  as  long  as  the  infant  is  deriving  nourish- 
ment from  the  mother,  she  ought  to  partake  of  good,  wholesome, 
nourishing  food,  that  the  blood,  deriving  these  principles  from  the 
food,  may  be  able  to  supply  them  in  turn  to  the  milk  from  which  it 
is  secreted.  So  long,  then,  as  the  child  is  thus  nourished,  so  long 
is  it  safe,  and  the  rudiment  or  foundation  of  a  robust  frame  is  laid. 
And  if  we  are  to  expect,  in  future  life,  tlie  stalwart  frame  of  man,  or 
the  enduring,  firmly-knit,  compact,  and  healthy  physical  constitution 
in  woman,  the  organic  and  inorganic  or  earthy  compounds  of  which 
that  frame  is  composed  must  not  be  denied.  Nature  must  be  sup- 
plied, or  nature  will  fail. 

"It  is  not  for  me  to  dictate  to  any  parent  what  shall  be  the  food 
of  his  child:  it  is  enough  that  I  point  out  for  their  information  what 
may  be  required  to  give  what  in  common  language  is  called  'bone 
and  sinew'  to  their  offspring.  It  is  necessary,  then,  that  the  food 
of  children  shall  contain: 

"  1st.  Aliment  having  the  calorifacient  or  heat-sustaining  prin- 
ciple. And  this  is  contained  in  quite  sufficient  quantity  in  the  usual 
food, — in  milk,  wheaten  bread,  potatoes,  arrow-root,  Indian  corn  (as 
mush,  hominy,  or  corn-bread),  in  most  vegetable  matter,  and  in 
sugar. 

"2d.  Aliment  containing  the  nutrient  principle.  And  this  is  con- 
tained in  animal  food, — the  lean  of  beast,  bird,  and  fish, — in  milk, 
eggs,  wheat,  rye,  potatoes,  beans,  etc. 

"And  3d.  Aliment  containing  the  inorganic  or  earthy  constitu- 
ents,— on  which  depends  strength  of  frame,  and  from  which  are 
formed  the  bones  and  teeth  of  the  individual.  And  these  are  con- 
tained in  milk,  eggs,  animal  food,  and  particularly  in' wheat,  rye, 
oats,  potatoes,  etc.* 

-  *  On  this  subject,  I  extract  the  following  from  Carpenter's  Physiology, 
p.  488:  "These  substances  are  contained,  more  or  less  abundantl}^,  in  most 


THE   TEETH  AND    THEIR   DISEASES.  245 

"  Of  the  inorganic  constituents  contained  in  wheat  (and  the  same 
may  be  said  of  the  other  cereal  grains)  I  have  ah-eady  alluded  to 
the  benefit  to  be  derived  from  using  bread  made  of  unbolted  flour. 
On  this  subject  allow  me  to  refer  to  the  difference  of  flour  having 
much  of  the  bran  i-emaining,  and  superfine  flour,  or  that  in  general 
use  throughout  this  country,  and  on  which  Prof.  Johnston  has  made 
the  following  curious  but  practical  observations.  Examining  wheat 
and  flour,  as  to  the  amount  of  the  nutrient  or  muscular  matter,  the 
fat-forming  principle,  and  the  bone  and  saline  material,  contained  in 
grain  in  different  states,  he  found — 

Muscular  matter.  Fat  principle.  Bone  and  salt. 

In  1000  lbs.  of  whole  grain  156  lbs.         25  lbs.         170  lbs. 

"  "  fine  flour 130"  20"  60" 

"  "  bran 60  "  700  " 

"  Taking  the  three  substances  together,  according  to  Prof.  John- 
ston, of  a  thousand  pounds,  the  three  substances  contain  of  the  in- 
gredients mentioned, — 


articles  generally  used  as  food  ;  and  where  they  are  deficient,  the  animal  suffers 
in  consequence,  if  they  are  not  supplied  in  any  other  way.  Thus,  common 
salt  exists,  in  no  inconsiderable  quantity,  in  the  flesh  and  fluids  of  animals, 
in  milk  and  in  eggs;  it  is  not  so  abundant,  however,  in  plants;  and  the 
deficiency  is  usually  supplied  to  herbivorous  animals  by  some  other  means. 
Phosphorus  exists  also  in  the  yolk  and  white  of  the  egg,  and  in  milk ;  and  it 
abounds  not  only  in  many  animal  substances  used  as  food,  but  also  (in  the 
state  of  phosphate  of  lime  or  bone-earth)  in  the  seeds  of  many  plants,  espe- 
cially the  grasses.  In  smaller  quantities,  it  is  found  in  the  ashes  of  almost 
every  plant.  Sulphur  is  derived  alike  from  vegetable  and  animal  substances. 
It  exists  in  flesh,  eggs,  and  milk  ;  also  in  the  azotized  compounds  of  plants; 
and  (in  the  form  of  sulphate  of  lime)  in  most  of  the  river-  and  spring-water 
that  we  drink.  Iron  is  found  in  the  yolk  of  egg  and  in  milk,  as  well  as  in 
animal  flesh  ;  it  also  exists  in  small  quantities  in  most  vegetable  substances 
used  us  food  by  man, — such  as  potatoes,  cabbage,  peas,  cucumbers,  mustard, 
etc.  Lime  is  one  of  tli£  most  universally  diffused  of  all  mineral  bodies;  for 
there  are  few  animal  or  vegetable  substances  in  which  it  does  not  exist.  It 
is  most  commonly  taken  in,  among  the  higher  animals,  combined  with  phos- 
phoric acid :  in  this  state  it  exists  largely  in  the  seeds  of  most  grasses,  and 
especially  in  wheat-flour.  If  it  were  not  for  their  deficiency  of  lime^  some  of 
the  leguminous  seeds  (peas)  would  be  more  nutritious  than  wheaten  flour ; 
the  proportion  of  azotized  matter  they  contain  being  greater.  A  consider- 
able quantity  of  lime  exists,  in  the  state  of  carbonate  and  sulphate,  in  all 
hard  water." 


246  ORAL  DISEASES  AND  SURGERY. 

Whole  grain.        Fine  flour. 

Of  muscular  matter •.  156  lbs.  130  lbs. 

Of  bone  material 170  "  60  " 

Offat 28  "  20  " 

354  lbs.  210  lbs. 

"Accordingly,  the  whole  grain  is  one-half  more  nutritious  than 
fine  flour.*  It  also  shows  the  very  great  proportion  of  bone  mate- 
rial— that  is,  earthy  constituents — contained  in  the  bran  ;  no  less 
than  700  out  of  a  thousand  parts,  or  a  little  more  than  two-thirds  of 
the  whole.  Now,  by  reference  to  the  same  work,  we  find,  in  a  com- 
munication from  a  Mr.  Bentz,  the  ditference  in  weight  of  a  barrel  of 
flour  without  the  bran,  and  when  only  the  outer  coating  of  the  wheat 
is  taken  off.  He  says,  'The  weight  of  the  bran  or  outer  coating 
would,  therefore,  in  the  common  superfine  flour,  constitute  the  ojfal, 
weighing  only  5^  lbs.  to  the  barrel  of  flour,  while  the  ordinary 
weight  of  offal  is  from  65  to  70  lbs.  to  each  barrel  of  flour  ;  showing 
a  gain  of  from  59|  to  65  lbs.  of  wheat  in  every  barrel  of  flour."  Now, 
if  we  estimate  the  earthy  constituents  to  be  two-thirds  of  the  offal 
or  bran,  we  must  consider  that  there  is  an  actual  loss  of  these  im- 
portant constituents,  which  might  be  reserved,  in  every  barrel  of 
flour,  of  40  lbs. 

"Again,  if  we  estimate  (according  to  the  average  of  the  consump- 
tion of  flour  to  the  amount  of  population,  as  one  barrel  to  each  indi- 
vidual) that  every  child  shall  consume  annually  only  half  a  barrel  of 
flour,  then  we  find  that  by  the  use  of  the  superfine  flour,  as  com- 
monly used  in  families,  the  child  is  deprived  yearly  of  twenty  pounds 
of  those  earthy  substances  which  are  required  to  form  the  bones  and 
the  teeth.  When  we  speak  of  a  child  consuming  half  a  barrel  of 
flour  annually,  it  appears  a  large  quantity;  but  when  we  reduce  the 
same  to  a  daily  allowance,  we  find  that  it  is  little  more  than  4  oz.  or 
4^  oz. ;  and  every  parent  must  know  that  this  would  be  a  very  small 
amount  to  limit  children  to.  Yet  we  see  how  large  a  quantity  of  the 
bony  material  would  be  added  if  unbolted  flour  was  used  instead  of 
the  present  superfine  flour.  I  ma}^  here  add  that  the  oatmeal  used 
in  Scotland,  already  referred  to,  contains  the  bran  or  inorganic  con- 
stituents, while  the  oatmeal  used  in  England  is  deprived  of  it.  Now, 
this  is  a  great  loss  of  the  most  valuable  constituents  in  only  one  of 
the  principal  articles  of  the  food  of  children;  and  if  we  allude  to 
another  article,  which  is  largely  used  on  this  continent, — I  mean 

*  Patent  Office  Eeport,  1847,  p.  116. 


THE   TEETH  AND    THEIR  DISEASES.  247 

Indian  coi"n  (and  I  may  also  add  the  fat  of  meat,  both  of  which, 
children,  if  allowed,  will  partake  of  very  freely), — we  shall  find  that 
both  of  these  abound  more  in  the  calorifacient  or  heat-sustaining 
principle,  and  for  the  deposition  of  fat,  than  the  nutrient,  and  that 
they  are  quite  deficient  in  the  earthy  material  of  lime, — that  material 
on  which  so  much  depends  the  proper  structure  of  the  teeth.  An- 
alysis of  Indian  corn  shows  the  following  composition, — as  taken 
from  Mr.  Salisbury's  prize  essay  read  at  the  New  York  Agricultural 
Society  for  1849 : 

Whole  kernel. 

Starch 50  G4 

Sugar  and  extractive 7  46 

Sugar 1-50 

Fibre 6-28 

Matter  separated  from  fibre 0-05 

Albumen 8  64 

Casein 1-70 

Gluten 4-56 

Oil 400 

Dextrine  or  gum 4  84 

Water 10-22 

99-89 
Ash  of  the  kernel,  constituting  about  two  per  cent. 

Carbolic  acid a  trace. 

Silicic  acid  1-450 

Sulphuric  acid 0  206 

Phosphoric  acid 50  955 

Phosphate  of  iron 4-355 

Lime 0  150 

Magnesia 16'530 

Potash 8-286 

Soda 10-908 

Chloride  of  soda 0-249 

Organic  acid 3-400 

97-000 

"  This  is  a  most  elaborate  analysis, — far  more  minute  than  any 
analysis  we  have  had  of  any  of  the  articles  of  food, — in  fact,  more 
minute  than  satisfactory;  for  the  analysis  of  the  whole  kernel  does 
not  exhibit  any  amount  of  inorganic  constituent;  and  when  the 
whole  is  converted  into  ashes,  we  find  that  the  lime  only  amounts 
to  the  one-sixth,  of  one  part  in  a  hundred.  Now,  on  inquiry,  I  find, 
on  the  authority  of  a  very  intelligent  miller  of  this  city,  that  in 


248  ORAL  DISEASES  AND   SURGERY. 

grinding  corn  the  bran  or  thin  skin  of  the  grain  is  detained  in 
forming  it  into  corn-meal ;  consequently,  it  is  deprived  of  even 
that  portion  more  particularly  containing  the  earthy  constituents. 
This  gentleman,  in  conversation,  mentioned  an  important  fact  rela- 
tive to  this  deficiency  of  lime  in  corn.  To  the  best  of  my  recol- 
lection, he  observed,  '  This  stands  to  reason ;  for,  ten  years  ago, 
all  the  lower  part  of  Jersey  grew  excellent  corn,  but  would  not 
grow  wheat ;  but  since  the  introduction  of  Ivme  as  a  manure  they 
have  raised  considerable  wheat  crops.'  Now,  the  fact  is,  it  is  not 
the  habit  or  food  of  this  plant,  even  had  lime  been  in  the  earth;  and 
magnesia  and  the  saline  manures  are  recommended  to  the  agricul- 
turist as  best  suited  for  its  proper  development. 

"  It  is  generally  looked  upon  as  invidious,  and  one  is  more  likely 
to  incur  odium  than  to  receive  credit  for  saying  one  word  against  a 
food  which  stands  so  high  in  public  estimation  and  is  so  universally 
used  over  this  continent.  Yet  it  must  not  for  one  moment  be  sup- 
posed that  I  condemn  the  use  of  Indian  corn  in  its  various  forms  of 
mush,  hominy,  bread,  or  pudding  as  an  article  of  diet;  far  from  it. 
But,  containing,  as  it  does,  a  large  proportion  of  starch  and  fatty 
matter,  rather  a  small  proportion  of  the  nutrient  principle,  and  quite 
a  deficiency  of  the  inorganic  or  earthy  constituents,  I  consider  it 
as  valuable,  as  a  light  diet,  for  heat-sustaining  purposes  only,  and 
therefore  a  desirable  adjunct  to  other  food,  containing  more  nutri- 
ment and  a  due  proportion  of  the  earthy  constituents. 

"As  an  example  or  illustration  of  the  want  of  the  nutrient  prin- 
ciple in  corn  or  corn-meal,  I  may  here  allude  to  the  effects  I  have 
seen  in  the  West  Indies,  where,  in  a  dearth  of  the  ordinary  pro- 
visions on  which  prisoners  were  fed,  corn-meal  was  substituted ; 
corn-meal  and  salted  herrings,  fish,  etc.,  constituting  their  food. 
Now,  the  effect  was  that  all  the  prisoners  lost  their  natural  strength ; 
at  the  same  time  they  became  fat  and  bloated,  inclining  to  dropsy. 
And  this  was  not  the  effect  of  incarceration  ;  for  the  prisoners  were 
engaged  in  road-making,  trimming  fences,  etc., — consequently,  in  a 
healthy  and  exhilarating  employment. 

"  In  reference  to  our  domesticated  animals,  it  may  be  asked.  Why 
is  corn  so  useful  as  an  article  of  food  to  animals  generally, — hoi'ses, 
hogs,  sheep,  etc.  ?  I  have  already  shown  that  the  overplus  of  the 
calorifacient  food,  after  what  may  be  required  for  sustaining  the 
temperature,  is  stored  away  in  the  form  of  fat.  Now,  if  we  instance 
the  horse,  corn  is  generally,  if  not  always,  given  as  an  adjunct  to 
his  more  usual  food, — hay.     And  we  find  by  an  analysis  that  grass 


THE   TEETH  AND    THE  IB  DISEASES.  249 

or  haj  contains  not  only  the  nutrient  principle,  but  the  inorganic 
constituents  required  in  the  formation  of  bone,  etc. 
"One  hundred  parts  of  dry  hay  contain — 

Carbon 45-8 

Hydrogen 5-0 

Oxygen 38-7 

Nitrogen* 1-5 

Ashesf 90 

100- 

"Thus,  the  hay  gives  to  the  animal  strength  in  bone  and  muscle, 
while  the  corn  supplies  additional  heat-sustaining  properties,  and 
lays  by,  in  the  form  of  fat,  the  overplus  as  a  reserve.  The  harder 
the  horse  is  worked,  the  more  corn  he  can  bear  ;  the  great  propor- 
tion of  the  carbon  being  carried  off  by  the  lungs,  and  the  hydrogen 
and  oxygen,  as  water,  in  exhalation  and  perspiration.  But  if  the 
sajue  quantity  is  given  to  a  horse  at  rest,  it  overloads  him  with 
fat,  which  in  his  case  accumulates  more  internally,  or  around  the 
internal  organs,  and  will,  in  course  of  time,  induce  disease;  while  in 
the  pig,  under  similar  circumstances,  the  fat  is  laid  on  externally,  if 
I  may  so  speak,  giving  the  rich  fat  pork  of  our  markets.  And  here 
I  would  again  remark  that  no  farmer  would  consider  it  necessary 
or  essential  to  give  corn  to  a  young  colt  or  horse,  until  required  to 
work  ;  nay,  so  careful  is  nature  in  appropriating  just  so  much  and 
no  more  of  any  constituent  that  may  be  required,  that  the  food  of 
the  young  horse  should  be  more  nutritious  than  heat-sustaining, 
and  that  there  shall  be  no  superfluity  to  store  away  fat,  we  find  by 
analysis  that  the  milk  of  the  mare  has  little  or  no  butter — in  fact, 
only  traces  of  it — in  its  composition. |  What  a  lesson  in  the  animal 
economy  is  here  given,  and  what  a  practical  illustration  of  the  re- 
quirements of  the  young  of  that  and  other  animals  ! 

"Again,  it  may  be  contended  that  among  the  beautiful  children 
we  see  on  every  hand,  there  is  no  want  of  those  who  are  fat  and 

*  Fifteen  pounds  of  such  hay,  containing  oz.  3  095  of  nitrogen. 

f  These  ashes  having  a  good  proportion  of  lime. 

X  Analysis  of  mare's  milk  : 

Water 896  3 

Butter traces. 

Casein 16  2 

Sugar  of  milk,  extractive  matters,  and  fixed  salts 87*5 

1000- 


250  ORAL  DISEASES  AND  SURGERY. 

hearty.  It  is  Moi  fat  we  want;  it  is  bone  and  muscle,  with  so  much 
fat  only  as  shall  give  firmness  to  the  flesh  and  plumpness  to  the 
figure.  Fat,  although  it  enters  intimately  into  union  with  the  other 
component  parts  gf  bone  and  muscle,  cannot  be  transformed  either 
into  the  inorganic  constituents  of  bone  or  teeth,  or  into  muscular 
fibre.  These  must  be  contained  in  the  food  consumed,  in  the  first 
place,  and  thence  transferred  to  the  blood. 

"How  necessary,  then,  how  important  it  is,  if  we  expect  to  give 
strength  and  vigor  to  the  constitution,  that  the  food,  in  the  tii'St 
years  of  infancy  and  childhood,  when  the  formative  process  is  going 
on,  should  receive  some  further  attention  than  has  hitherto  been 
given  to  it!  and  if  our  youth, — if  our  young  females  have  hitherto 
been  deprived  of  the  necessary  constituents  for  the  full  development 
of  every  portion  of  the  body, — can  we  wonder  that  a  woman  should 
be  the  delicate  and  fragile  being  she  is,  or  that  by  the  decay  which 
assails  the  teeth  in  early  life  she  should  be  deprived  of  an  orna- 
ment of  so  much  value  ?  If  this  state  of  things  can  be  altered, — if 
the  physical  constitution  of  woman  in  America  can  be  saved  from 
further  degeneracy,  —  a  purpose  may  be  effected  of  consequence 
even  in  a  national  point  of  view;  for  it  is  to  the  healthy  and  vigor- 
ous constitution  of  woman  that  we  must  look  for  a  race  of  hardy, 
vigorous,  and  enterprising  freemen. 

"  In  conclusion,  I  would  briefly  state  that  this  is  a  matter  in 
which  professional  aid  can  avail  little ;  it  lies  at  the  door  and  must 
be  the  work  of  parents  generally.  It  is  for  them  to  understand  the 
great  value  to  be  attached  to  the  food  on  which  their  children  sub- 
sist,— that  it  shall  be  wholesome  and  nutritious,  and  abounding  in 
the  earthy  compounds  so  absolutely  necessary  to  their  proper  de- 
velopment. If  the  chief  articles  of  food  have  hitherto  consisted  of 
compounds  made  of  superfine  flour,  corn-meal,  and  the  fat  of  meat, 
let  there  be  substituted  in  their  stead  bran-bread,  milk,  eggs,  the 
lean  of  meat,  and  potatoes;  let  more  attention  be  given  to  the  nu- 
trient quality  of  the  food  ;  let  there  be  no  deficiency  of  those  articles 
containing  the  earthy  material,  that  the  bones  and  teeth  shall  not 
be  deficient  in' those  constituents  so  necessary  in  their  composition 
and  structure  ;  and  I  should  be  inclined  to  hope  that  the  evils  which 
now  exist  will  be  lessened,  and  the  physical  organization  of  suc- 
ceeding generations  be  equal  to  that  of  any  nation  upon  earth." 

From  these  hereditary  and  primal  associations  of  dental  caries  we 
may  now  feel  ourselves  prepared  to  pass  to  local  considerations ; 


THE   TEETH  AND    THEIR  DISEASES.  251 

and  this  brings  us  to  the  second  of  our  premises, — namely,  the  shape 
of  the  teeth,  their  relation  to  each  other,  and  their  self-cleansing 
features. 

Fig.  59. — Superior  Dextal  ArcH. 


Fig.  60. — Superior  Dkntal  Arch. 


On  examining  the  two  arches,  Figs.  59  and  60,  the  observer  will 
instantly  be  struck  with  the  decided  difference  presented.  In  the 
first.  Fig.  59,  is  represented  a  denture  which,  mechanically  speak- 
ing, may  be  pronounced  perfect,  every  tooth  having  a  harmonious 
relation  with  its  fellow,  and  each  individual  tooth  being  perfect  in 
itself. 


252  ORAL  DISEASES  AND   SURGERY. 

In  the  second  of  the  diagrams,  Fig.  60,  the  artist  has  exhibited 
imperfections  which,  in  truthfulness  to  nature,  have  been  extended 
to  every  individual  tooth,  even  to  the  crowding  and  wedging  of 
them  which  are  so  frequently  to  be  seen.  Examining  the  molar  teeth, 
the  grinding  faces  are  seen  more  or  less  pitted.  These  sulci  are 
generally  found  uncovered  at  some  point  by  enamel,  an  imperfection 
so  common  as  to  render  these  less  resistive  than  their  fellows. 
Hence  caries  is  most  frequent  in  this  class.  Particularly  is  this 
the  case  with  the  denies  sapientiae,  an  operculum  of  gum  being 
too  often  found  an  added  cause  of  offense.  To  write  any  exact 
description  of  the  irregularities  of  the  faces  of  the  molar  teeth  would 
be  impossible,  owing  to  the  diversified  aspects  presenting  them- 
selves. Sometimes  such  sulci  are  double,  crossing  each  other  at 
right  angles.  Frequently  a  single  depression  will  separate  the  face 
into  two  principal  cusps,  and,  running  over  the  side,  will  terminate 
in  a  pit.  Still  again  a  single  deep  sulcus  will  occupy  the  very  centre 
of  the  grinding  face,  the  four  cusps  being  more  or  less  associated 
and  ranged  around  it,  ring  fashion.  In  still  other  cases,  a  multitude 
of  pits  will  cover  the  surface  :  on  a  single  face  I  have  counted  as 
many  as  fifteen. 

The  bicuspidati,  for  a  similar  reason,  are  markedly  subject  to  be 
attacked  These  teeth  not  only  decay  from  their  cutting  face,  but, 
because  of  a  peculiar  flatness  characteristic  of  their  proximal  sur- 
faces, are  more  frequently  attacked  upon  the  sides  than  even  upon 
the  grinding  surface  above. 

The  next  in  the  order  of  liability  are  the  incisors  of  the  upper 
jaw.  Observation  of  the  diagram  exhibits  a  flatness  on  the  pala- 
tine face  of  these  teeth,  which  in  many  instances  falls  into  a  positive 
sulcus.  These  pits  it  is  impossible  to  keep  clean  :  hence  an  antagon- 
ism which  results  in  caries.  The  surface  of  these  teeth  most  liable, 
however,  to  suffer  from  caries,  is  the  proximal.  This  in  many 
instances  finds  explanation  in  the  constant  abrasion  here  going  on  as 
the  result  of  motion  produced  by  the  act  of  mastication,  the  enamel 
being  literally  worn  or  cracked  away.  In  other  instances,  a  species 
of  pocket-like  flatness  is  found  near  the  necks,  in  which  is  lodged  and 
retained  the  debris  of  diet.  In  still  other  instances,  the  dentine 
becomes  deprived  of  its  protecting  enamel  as  the  result  of  lateral 
pressure,  such  pressure  being  increased  with  the  development  of  each 
new  tooth  ;  this  applies  most  particularly  when  the  relation  of  ap- 
proximal  contact  is  a  limited  one  and  not  diffused  over  the  face  of 
the  tooth  at  lartre. 


THE   TEETH  AND    THEIR  DISEASES.  253 

The  inferior  incisors  and  cuspidati  are  tlie  teeth  least  disposed  to 
decay.  An  explanation  of  such  exception  seems  found  in  the  shape 
of  these  organs  and  in  their  being-  fully  surrounded  by  an  antiseptic 
saliva. 

The  wisdom  teeth,  universally  viewed  as  being  most  predisposed 
to  caries,  derive  such  tendency  from  a  twofold  direction.  Developing 
at  a  period  when  the  formative  force  is  losing  vigor,  these  teeth 
are  commonly  deficient  in  the  amount  of  that  inorganic  mate- 
rial which  constitutes  what  might  be  called  the  mechanical  resist- 
ance of  the  dental  organs  :  in  structure  they  are  found,  comparatively 
speaking,  loose,  while  their  general  resistive  power  is  low;  they 
might,  indeed,  be  likened  to  the  osteophytes  which  form  after  bone 
operations,  and  which  represent  so  imperfectly  the  tissue  replaced, 
being  found  unable  to  resist  antagonisms  not  at  all  injurious  to 
properly-formed  tissue.  Again,  as  a  local  signification  is  concerned, 
these  teeth,  making  their  appearance  at  a  period  when  all  the  other 
teeth  are  formed,  find  so  little  room  in  the  arch  as  to  render  the 
process  of  eruption  difficult,  slow^,  and  in  some  cases  impossible: 
hence  not  only  is  a  chronic  morbidity  engendered,  but  the  face  of 
the  tooth  is  in  many  instances  so  long  overlaid  by  an  unabsorbed 
operculum  (see  diagram)  that  a  perfect  pocket  exists,  constantly 
filled  by  ingesta. 

Condition  3.  Constitutional  Relations. — This  is  the  purely  medi- 
cal aspect  of  the  question  :  it  considers  the  varying  changes  in  the 
individual  as  manifested  in  the  changes  of  dental  health, — whether 
such  relation  resides  in  altered  nutrition  of  the  organs  or  in  the 
production  of  adverse  associated  expressions.  An  example  is  fur- 
nished in  the  condition  of  utero-gestation,  a  second  in  dyspepsia,  a 
third  in  the  anemic  diseases. 

The  common  proverb,  "  for  every  child,  a  tooth,"  has  passed  into 
general  acceptation :  statistics  demonstrate  that  women  lose  their 
teeth  in  a  twofold  proportion  to  men,  and  that  child-bearing  women 
lose  them  in  a  threefold  proportion  to  single  women.  Teeth  which,  up 
to  a  period  of  pregnancy,  never  required  attention,  will,  in  some  in- 
dividuals, be  attacked  by  a  malignancy  of  carious  action  that  shall 
quickly  destroy  a  whole  denture;  such  caries  having  the  twofold 
signification  of  a  perverted  nutrition  and  antagonistic  local  action. 

An  all-important  question  here  presenting  itself  is  the  cure.  To 
esteem  this  as  residing  in  plugs  of  gold,  and  to  so  practice,  is  to  find 
one's  self  resting^  upon  a  staff  of  reed.     The  matter,  primarily,  is 


254  ORAL  DISEASES   AND   SURGERY. 

solely  one  of  nutrition  ;  not  that  necessarily  phosphate  of  lime  or 
other  special  material  is  demanded;  the  patient  may  have  of  such 
agents  quite  enough,  both  for  teeth  and  foetus  ;  but  the  presence 
of  agents  of  nutrition  is  not  nutrition.  Repair  in  living  tissues 
resides  in  that  function,  as  expressed  by  the  physiologist,  "  by  which 
nutritive  matter,  already  elaborated  by  the  various  organic  actions, 
loses  its  own  nature  and  assumes  that  of  the  different  living  tissues, 
to  repair  their  losses  and  support  their  strength."  Here  lies  the  indi- 
cation :  it  is,  to  correct  the  morning  sickness  which  compels  the 
stomach  to  refuse  its  food  ;  to  keep  cleansed  an  alimentary  canal 
which,  because  of  perverted  secretions,  is  denied  the  office  of  its  lac- 
teals,  the  whole  economy  thereby,  Tantalus-like,  being  starved,  even 
with  plenty  around;  it  is  to  antagonize  the  perversions  of  appetite, 
which,  refusing  proper  pabulum,  craves  substances  injurious  to  the 
health  at  large  ;  it  is  to  control  nervous  irregularities.  To  express 
the  requirements  in  one  sentence,  it  is  to  secure,  and  to  preserve  to 
the  system,  that  assimilative  force  through  which  it  may  be  enabled 
to  add  to  its  ordinary  functional  work  the  new  labor  demanded. 

Dyspepsia  and  anaemia,  as  causes  of  dental  caries,  have  the  same 
general  constitutional  signification  as  found  in  the  condition  just 
referred  to.  To  enter  into  a  discussion  of  these  relations  would,  as 
is  seen,  carry  us  necessarily  over  the  grounds  of  general  medicine, — 
a  domain  with  which  it  has  been  taken  for  granted  the  reader  is 
familiar. 

Condition  4.  Character  of  Agents  in  Contact  with  the  Teeth. — 
The  idea,  as  commonly  held,  that  caries  of  the  teeth  depends  exclu- 
sively on  the  existence  of  free  acids  in  the  oral  cavity,  is,  to  the 
mind  and  experience  of  the  writer,  a  proposition  which  needs  but 
little  correct  observation  to  limit  it  to  very  circumscribed  boundaries. 
If  any  one  hundred  mouths  be  taken,  having  in  them  carious  teeth, 
and  the  ordinary  test  by  litmus-paper  be  made,  four-fifths  of  them 
will  be  found  neutral,  if  not  alkaline.  Alkalinity  we  would  infer, 
then,  to  be  a  more  common  association  of  caries  than  acids;  and  of 
the  truth  of  such  position  experiment  will  show  that  there  can  be 
little  doubt.  It  is,  however,  a  truth  that  the  presence  of  any 
alkali  may  result  in  the  formation  of  an  eroding  acid  in  a  depression 
or  sulcus,  and  it  does  this  precisely  as  the  same  effect  results  in 
decaying  woody  fibre,  —  namely,  by  enabling  substances  to  absorb 
oxygen  which  do  not  in  themselves  possess  such  power,  or  possess 
it  to  a  very  limited  extent.     Thus,  perhaps  in  every  mouth  in  which 


THE   TEETH  AND    THEIR  DISEASES.  255 

the  fluids  are  alkaline,  carbonic  acid  will  be  found  in  the  debris  of 
decaying  teeth. 

Mucous  Dej^onits. — Every  one  who  has  occasion  to  make  observa- 
tions in  the  mouth  has  met  most  frequently  with  that  condition  of 
the  mucoid  secretion  in  which  this  fluid  is  glairy  and  tenacious, 
alkaline  to  the  test,  and  not  unfrequently  offensive  in  odor, — a  con- 
dition universally  associated,  when  a  habit,  with  dental  caries,  and, 
indeed,  with  general  dyscrasia.  Teeth  in  such  a  mouth  are  univer- 
sally covered  with  a  film,  and  this  so  persistent  that  the  ordinary 
use  of  the  brush  fails  to  disperse  it,  while  the  common  dentifrices 
have  alone  the  signification  of  a  temporary  good. 

Teeth  so  diseased  find  relief  alone  in  acids,  not  only  locally 
employed,  but  internally  administered.  A  system  secreting  such 
mucus  may  be  said  to  labor  under  the  dyscrasia  of  super-alkaline 
poisoning,  the  agent  having  its  point  of  exhibition  most  markedly 
in  the  mouth.  It  is  really  the  condition  of  oral  typh  fever, — a 
typhoid  condition  expressing  itself  in  this  particular  secretion,  pre- 
cisely as  in  other  instances  accident  might  have  directed  it  to  the 
degeneration  of  the  glands  of  Peyer  or  of  the  liver.  A  poi^n  is  in 
the  blood,  and  by  means  of  the  circulation  is  diffused  throughout 
every  part  of  the  system  ;  that  it  expends  its  force  most  markedly 
on  certain  parts  is  not  unlike  the  expression  of  disease  in  general. 
If  the  blood  of  a  patient  laboring  under  this  typh  condition  be 
examined  under  a  microscope,  it  will  be  found  that  the  normally- 
shaped  red  disks  are  diminished  in  number  as  compared  with  what 
are  known  to  the  pathologist  as  "  the  melanosed"  corpuscles  ;  that  is 
to  say,  as  expressed  by  Chambers,  "  the  dying  or  dead  disks,  shriv- 
eled and  small,  of  a  dark  color,  with  black  specks  in  them,  and  with 
gimped  edges." 

But  what  is  this  typh  poison,  it  may  be  asked?  Unfortunately, 
the  nature  and  scope  of  the  present  volume  limit  an  answer  to  the 
simple  elements  of  one  of  the  most  interesting  questions  in  medicine. 
By  typh  poison  is  meant  the  existence  in  the  blood  of  a  super-alka- 
linity, which  tends  to  dissolve  the  blood-corpuscles  and  to  defeat  the 
ends  of  tissue-metamorphosis.  This  poison,  according  to  its  quan- 
tum, depresses  to  death,  as  seen  too  often  in  cases  of  typhoid  fever, 
or  it  may  expend  itself  in  a  simple  deranged  vitality,  as  witnessed 
in  the  stringy  mucus  now  under  consideration.  How  this  poison 
enters  the  system,  necessarily  provokes  much  discussion.  That 
one  of  its  inroads,  however,  is  by  the  stomach,  is  not  to  be  doubted, 
seeing  that  in  epidemic  typhoid  fever  an  emetic  at  the  beginning  of 


256  ORAL   DISEASES  AND   SURGERY. 

an  attack  seldom  fails  to  lessen  the  force  and  extent  of  the  impression, 
such  emetic  seeming  to  act  mechanically  by  emptying  the  stomach, 
thus  preventing  all  the  poison  which  had  been  received  into  that 
viscus  from  being  taken  up ;  while  still  again  it  is  observed  that 
during  the  prevalence  of  such  epidemics,  those  who  smoke  and 
chew  tobacco,  and  thus  eject  their  saliva,  are  least  apt  to  be  attacked. 

That,  however,  the  typh  poison  may  be  generated  from  within,  is 
scarcely  to  be  doubted.  In  such  chronic  cases  as  associate  with  dental 
caries,  this  is  the  direction,  no  doubt,  of  the  production  ;  and  yet  the 
condition  may  reside  in  a  subacidity,  the  alkalinity  being  what 
might  in  proper  health  be  normal,  but  which  is  in  excess  from  the 
deficiency  of  a  neutralizing  acid.  Unable,  however,  to  devote  a 
greater  space  to  the  consideration  of  a  question  well  worthy  a  chapter 
in  itself,  we  leave  the  subject  with  this  hasty  glance,  extracting  the 
deduction  that  the  prophylaxis  of  caries  in  this  direction  is  found  in 
the  free  use  of  acids.  If  to  tjje  mind  of  any  one  this  may  need  con- 
firmation, let  a  deduction  be  drawn  from  any  two  cases  of  ordinary 
typhoid  fever, — one  being  treated  with  alkaline  medicines,  the  other 
with  ^ids.  In  seven  cases  out  of  ten,  the  patients  treated  exclu- 
sively with  the  first  will  die ;  seven  out  of  ten  treated  with  acids 
will  recover.* 

As  a  systemic  medicament,  let,  therefore,  the  following  be  pre- 
scribed : 

R. — Acidi  hydrochlorici  diluti,  gtt.  x; 
Syrupi,  5ss; 
AqusB,  5j-         M. 

S. — To  be  repeated  from  one  to  three  times  a  day,  as  may  seem 
required ;  or  it  might  be  that  even  five  drops  of  the  acid  would  be 
found  sufficient  for  the  requirements.  In  cases  of  typhoid  fever,  I 
have  administered  as  many  as  twenty-five  drops  as  a  dose,  repeated 
every  three  hours  for  two  weeks. 

Conjoined  with  the  acid  it  will  be  found  serviceable  to  employ  the 
quiniae  sulphas, — a  grain  pill  once  or  twice  a  day,  according  to  the 
length  of  time  it  is  proposed  to  continue  the  medicine.  A  very  good 
plan  is  to  direct  thirty  pills  : 

R. — Quinise  sulphatis,  gr.  xxx; 
Extracti  gentianae,  3j-         M. 

*  This  assertion  is  founded  on  observations  made  in  daily  attendance  on 
quite  a  number  of  patients  during  an  epidemic  lasting  nine  months. 


THE   TEETH  AND    THEIR   DISEASES.  257 

To  be  divided  into  pills  No.  sxx ;  one  or  more  to  be  taken  each 
day. 

Asa  mouth-wasb,  the  following  combination  will  be  found  appli- 
cable : 

B. — Tincturae  capsici  compositse,  5ij ; 
Aquae  Coloniae,  5ij ; 
Spiritus  vini,  §ij ; 
Tincture  quillai,  siss  ; 
Tincture  gentianae  compositae,  §j; 
Acidi  acetici  diluti,  §ss; 
Acidi  carbolici  fluidi,  ^ij.         M. 
S. — To  be  used  by  saturating  a  tooth-brush  which  has  been  first 
dipped  into  water. 

Where  much  ofFensiveness  in  odor  is  associated  with  this  in- 
spissated mucus,  it  may  be  necessary  to  use  a  gargle  of  the  per- 
manganate of  potassa  or  of  the  aqua  chlorinata.  For  the  former, 
a  very  good  proportion  would  be  as  follows  :  • 

B. — Potassae  permanganatis,  gr.  xv; 
Aquae,  o^iij-         M. 
S. — Use  as  required. 

Still  another  most  excellent  preparation  for  such  disinfection  is 
the  phenate  of  soda ;  indeed,  by  many,  preference  is  given  to  this 
article  above  most  others.  It  is  used  diluted  with  water  in  such 
proportions  as  seem  demanded  to  meet  the  indication  of  the  special 
cases  prescribed  for, — ordinarily  one  part  of  the  phenate  to  ten  parts 
of  water. 

Acid  Secretions. — That  the  common  oral  fluids  are  occasionally 
to  be  found  of  an  acidity  sufficiently  strong  to  be  injurious  to  the 
limy  structure  of  the  teeth  is  not,  of  course,  to  be  denied.  When 
such  state  exists,  it  is  easily  to  be  demonstrated  by  furnishing  the 
patient  with  a  few  strips  of  litmus-paper,  which  are  to  be  wet 
with  the  fluids  of  the  mouth  at  varying  periods  of  the  twenty- 
four  hours.  In  the  morning,  immediately  upon  rising  and  before 
taking  fluids,  is  the  test  perhaps  of  most  signification.  If  such  test 
reddens  the  paper  for  a  series  of  mornings,  an  antacid  indication 
would  seem  to  be  fairly  established,  and  local  prescriptions,  some- 
thing in  combination  like  the  following,  may  be  directed  : 

17 


258  ORAL  DISEASES  AND  SURGERY. 

R. — Aqus6  calcis,  siv  ; 
Tincturse  cinchonse, 
Tincturge  pyrethri,  aa  ^j  ; 
Tincturse  quillai,  gij ; 
Potassse  cbloratis,  5j ; 
Aquae  chlorinatse,  5ij ; 
Spiritus  vini,  5j ; 
Tincturi^  gaultherise,  q.  s.     M. 
S. — To  be  used  with  the  tooth-brush. 

Or, 

R. — Potassfe  chloratis,  5ss  ; 

Aquae,  giij ; 

Tincturse  capsici  compositse,  5'j  5 
Aqu»  Coloniae,  5j  I 
Tincturse  quillai,  siss; 
Olei  limonis,  vel  verbenae,  vel 
gaultheriae,  q.  s.     M. 
S.— To  be  used  with  the  brush. 

If  it  prove  more  convenient  to  employ  poAvders,  something  like 
the  following  will  be  found  to  answer  the  required  purpose: 

R. — Cretae  praeparatse, 

Iridis  Florentince  pulveris,  aa  ^ss; 
Ossis  sepiae  pulveris,  5ij ', 
Olei  limonis,  q.  s.         M. 
Or, 

R. — Cinchonae  rubrae  pulveris,  5ij  ; 
Capsici  pulveris,  gr.  x; 
Potassae  chloratis  pulveris,  5j  5 
Pulveris  aromatic!,  5'j ; 
Saponis  castiliensis  pulveris,  ^j  ; 
Magnesiae  carbonatis,  5ss ; 
Iridis  Florentinae  pulveris,  ^j.     M. 

Conjoined  with  the  local  antacids,  attention  is  likewise  demanded 
to  the  functional,  or  it  may  be  organic,  conditions  producing  the 
acids.  Different  derangements  of  the  general  health  will  exhibit 
different  acids.  Thus,  in  one  mouth  will  be  found  the  uric,  in  an- 
other the  lactic,  in  still  another  the  nitrous,  etc.  These  productions 
have  their  constitutional  meaning  and  indications.    As  examples  in 


THE   TEETH  AND    THEIR   DISEASES.  259 

such  directions  of  practice,  the  presence  of  uric  acid  in  the  mouth, 
as  in  the  urine,  would  be  most  apt  to  be  found  associated  with 
deficiency  in  respiratory  action  and  with  circulatory  sluggishness. 
Lactic  acid  in  the  saliva  would  almost  certainly  indicate  the  con- 
dition of  diabetes,  although  diabetes  does  not  necessarily  yield  lactic 
acid  to  the  saliva.  Formic  and  acetic  acids  found  continuously  in 
certain  mouths  have  been  made  quickly  to  disappear  through  treat- 
ment directed  to  an  existing  leukaemia. 

Farasites. — The  parasitic  theory  of  dental  caries  holds  good  only 
as  fungi,  animal  or  vegetable,  are  added  causes  of  deterioration. 
Lodged  in  a  cavity  of  a  tooth  of  soft  structure,  these  no  doubt  act 
the  part  of  destructive  agents,  by  insinuating  themselves  into  the 
tubular  and  intertubular  spaces,  interfering  with  and  counter- 
balancing the  resistive  efforts  of  dentinal  consolidation,  and  serving 
as  sponge-like  bodies,  to  hold  in  contact  with  the  parts  agents  alike 
injurious  with  themselves,  lowering  also  the  resistive  vitality  through 
an  appropriation  of  nutritional  pabulum. 

To  destroy  these  fungi,  few  agents  will  be  found  more  reliable 
than  what  is  known  as  the  dental  carbolic  acid  soap.  This  soap 
should  be  used  twice  a  day,  and  particularly  is  not  to  be  neglected 
on  retiring  for  the  night.  Powders  also  serve  an  excellent  purpose, 
removing  the  offense  mechanically.  Acid  washes,  as  suggested, 
may  also  be  prescribed.  Dr.  Aitkin,  of  Edinburgh,  recommends 
the  production  in  the  mouth  of  sulphurous  acid  through  a  solution 
of  the  sodae  sulphis  : 

B. — Sodae  sulphitis,  5j ; 
Aquae,  f5J. 

In  proportion  as  the  secretions  are  acid,  the  salt  is  decomposed, 
the  sulphurous  acid  being  set  free.  This  disengaged  acid  will,  it  is 
affirmed,  destroy  the  parasites  in  twenty-four  hours. 

In  the  case  of  a  family  of  children  where  parasitic  offense  was 
associated  most  markedly  with  putrescent  caries,  a  change  quite 
wonderful  in  its  character  was  produced  by  alternations  of  acid 
and  alkaline  washes.  Either  of  these,  by  itself,  failed  utterly  in 
any  satisfactory  result.  I  was  led  to  infer,  therefore,  that  two 
orders  of  fungi  harmoniously  existed, — the  one  impressible  by  acids, 
the  other  by  alkalies;  and  the  result  of  the  treatment  certainly  seemed 
to  verify  the  conclusion.  The  fluids  of  all  the  mouths  were  neutral. 
The  Protococcus  dentales,  very  minute  organisms,  are  referred  to  by 
microscopists  as  being  most  frequently  found   in  carious  dentine, 


260  OBAL  DISEASES  AND   SURGERY. 

although  it  is  not  at  all  uncommon  to  meet  in  profusion  the  spi- 
rilla, amoebae,  monads,  etc. 

The  following  examinations,  made  by  Dr.  Joseph  G.  Richardson 
(author  of  the  "  Handbook  of  Medical  Microscopy")  on  the  first  five 
patients  coming  into  the  office  of  the  author  after  completion  of  the 
required  arrangements,  will  be  read  with  interest: 

Specimen  I. — Patient,  young  lady.  Mouth  remarkably  healthy- 
looking;  gums  hard  ;  had  lost  no  teeth  ;  cavities  very  few  in  num- 
ber; oral  fluids  neutral;  teeth  clean;  no  tartar  or  other  collections, 
specimen  examined  being  a  particle  of  carious  dentine.  Examination 
with  a  one-twenty-fiftb-inch  objective,  giving  with  the  No.  1  eye- 
piece a  power  of  about  twelve  hundred  diameters,  showed  multi- 
tudes of  bacteria  and  short  leptothrix  filaments,  all,  however,  quite 
motionless. 

Specimen  II. — Old  lady.  Teeth  breaking  down  in  every  direc- 
tion;  diffused  collection  of  pasty  debris;  gums  soft  and  unhealthy- 
looking;  epithelial  cancer  involving  left  half  of  lower  lip,  and  pass- 
ing around  the  commissure  to  upper  lip  ;  patient  very  deficient  in 
vital  force.  Specimen  examined  being  debris  from  the  side  of  an 
inferior  cuspis,  against  which  rested  the  disease.  Exhibited  long 
bundles  of  leptothrix  filaments,  consisting  of  from  five  to  fifty  my- 
celial threads,  each  about  one-ten-thousandth  of  an  inch  in  diameter, 
and  sometimes  attaining  the  enormous  length  of  one-tenth  of  an 
inch.  These  fibrous-looking  bundles  were  interlaced  and  imbedded 
in  a  large  amount  of  granular  stroma,  apparently  composed  in  great 
measure  of  bacteria  and  bacteridia,  as  many  of  the  former  could  be 
seen  in  very  active  movement  around  the  margins  and  in  the  inter- 
stices of  the  masses. 

Specimen  III.  —  Patient,  young  lady.  Mouth  in  the  highest 
degree  healthy-looking ;  had  lost  no  teeth ;  very  few  cavities,  and 
these  all  filled  beautifully  and  perfectly  with  gold  ;  fluids  neutral ; 
no  tartar.  Specimen  examined  being  a  mere  particle  of  debris  found 
between  the  inferior  central  incisors.  Showed  also  great  numbers 
of  comparatively  short  leptothrix  filaments,  among  whose  interstices 
floated,  in  molecular  (Brunonian)  movement,  multitudes  of  bacte- 
ridia and  nearly  motionless  bacteria.  A  few  of  these  minute  organ- 
isms manifested  voluntary  action,  which  continued  in  certain 
instances  for  at  least  thirty -six  hours  after  removal  from  their  parent 
mouth  and  immersion  into  the  three-quarter  per  cent,  salt  solution. 

Specimen  IV. — Boy  with  hare-lip.  Oral  fluids  alkaline,  stringy, 
and  tenacious.     Specimen  examined  being  carious  dentine  from  a 


THE   TEETH  AND    THEIR   DISEASES.  261 

lower  molar.  Showed  immense  numbers  of  bacteria,  short  leptothrix 
filaments,  chains  of  spores,  and  occasionally  a  specimen  of  spiril- 
lum. These  fungi  were  especially  abundant  around  the  margins  of 
dentine  scraped  from  the  cavity;  and,  as  they  were  not  accompanied 
by  salivary  leucocytes,  it  is  probable  that  they  did  not  proceed  from 
the  saliva,  but  had  developed  within  the  tooth. 

Specimen  V. — A  molar  tooth  with  a  large  cavity  in  its  side  was 
extracted  from  the  mouth  of  fifth  patient,  a  scrofulous  lady,  with 
most  unpromising  teeth,  and,  after  being  split  open,  was  subjected 
to  examination.  The  branch  of  the  cavity,  extending  into  one  of 
the  fangs,  was  filled  with  a  soft  spongy  mass,  which,  under  the 
microscope,  was  seen  to  be  composed  of  long  interlacing  filaments 
of  leptothrix  buccalis,  such  as  were  found  in  Specimen  IT.,  and  to  be 
swarming  with  bacteria. 

A  portion  of  the  cavity  at  the  edge  of  the  split  surface  was  scraped 
clean,  and  thin  sections  of  the  still  firm  but  diseased  dentine  were 
made  with  a  strong  sharp  knife.  These  fragments,  when  examined 
with  a  power  of  twelve  hundred,  were  seen  to  be  associated  wnth 
many  bacteria  and  filaments  of  leptothrix,  the  latter  of  which  seemed 
in  several  instances  to  occupy  the  dentinal  tubules  and  to  project 
from  their  fractured  extremities.  Although  being  then,  of  course, 
without  movement,  it  was  difficult  to  say  with  absolute  certainty 
that  the  structureless  fibre-like  bodies  were  actually  portions  of  the 
vegetable  growth. 

Electro-chemical  Relations. — Every  observer  must  have  remarked 
how  much  more  common  is  caries  to  moist  than  to  dry  mouths,  and 
how  much  more  common  is  the  failure  of  an  approximal  plug  at  the 
base-wall  than  elsewhere  about  its  circumference.  These  conditions 
have  been  discussed  by  Mr.  Kencely  Bridgman,  L.D.S.,  in  a  paper 
on  the  electro-chemical  action  of  metallic  substances  upon  the  teeth, 
with  an  exhibition  of  experimental  research  and  learning  which 
commends  his  views  to  the  most  respectful  consideration. 

"While  investigating,"  says  this  observer,  "the  action  of  voltaic 
electricity  upon  organic  compounds,  it  was  observed  that  all  defects 
of  metallic  fillings  in  the  teeth  could  be  represented  by  results  ob- 
tained out  of  the  mouth.  That  decay  might  be,  and  probably  was, 
a  chemical  action,  every  one  was  quite  ready  to  admit;  but  how  it 
could  be  electro-chemical  did  not  appear  to  be  in  the  slightest  de- 
gree comprehended.  The  immediate  effects  of  chemical  action  could 
easily  be  recognized  as  such  ;  but  the  previous  electric  condition 
giving  rise  to  this  chemical  action  required  a  somewhat  intimate 


262  ORAL  DISEASES  AND   SURGERY. 

acquaintance  with  the  laws  of  physical  forces  to  render  its  presence 
appreciable ;  and,  consequently,  the  only  valuable  portion  of  the  theory 
has  hitherto  been  left  in  abeyance." 

A  basal  experiment  upon  which  the  deductions  of  Mr.  Bridgaian 
are  founded  is  as  follows: 

"A  rod  of  absolutely  pure  zinc,  three  and  a  quarter  inches  long, 
after  being  thoroughly  amalgamated  with  fresh  distilled  mercury 
and  drained,  and  weighing  four  hundred  and  eighty-seven  grains, 
M'as  placed  half  its  length  in  cold  dilute  sulphuric  acid,  and  the 
other  half  exposed  to  the  atmosphere,  in  the  same  position  as  the 
ordinary  plates  of  a  battery.  In  a  very  short  time  bubbles  of 
hydrogen  made  their  appearance  over  the  whole  surface  exposed 
to  the  acid,  and  after  forty-eight  hours  the  metal  was  found  to  have 
lost  upwards  of  ten  grains  iu  .weight.  This  loss,  however,  was  by 
far  the  least  important  part  of  the  results  obtained.  The  immersed 
portion  of  the  metal  had  not  been  acted  upon  uniformly  over  its 
whole  surface  ;  but  the  action  had  been  greatest  at  the  surface  of  the 
liquid.  At  the  same  time  the  exposed  portion  had  become  covered 
with  patches  of  crystalline  sulphate  of  zinc,  high  and  dry  upon  the 
projecting  portion  of  the  metal.  Therefore,  not  only  had  chemical 
action  been  exerted  between  the  metal  and  the  acid  and  the  Avater 
decomposed,  but  there  was  the  additional  evidence  that  the  metal 
itself  had  become  polarized." 

Associated  with  this  first  is  the  repetition  by  Faraday,  copper 
being  used  instead  of  the  amalgamated  zinc,  the  color  of  the  crystals 
and  the  coloring  of  the  acid  affording  more  conspicuous  evidence  of 
the  results  produced. 

"A  piece  of  stout  copper  wire  being  placed  similarly  in  acid,  the 
latter  very  soon  gave  signs,  by  the  coloring  it  received,  of  the  copper 
commencing  to  undergo  solution  ;  and,  after  having  been  suffered  to 
remain  undisturbed  for  twenty  days,  it  presented  the  appearance 
above  the  acid  of  a  bushy  rod,  the  portion  exposed  to  the  atmos- 
phere becoming  coated  with  a  layer  of  minute  and  beautiful  crystals 
of  sulphate  of  copper,  extending  from  near  the  top  to  within  three- 
sixteenths  of  an  inch  of  the  liquid.  At  this  intermediate  portion  a 
greater  amount  of  chemical  action  had  been  induced,  corroding  the 
wire  about  half-way  through  and  forming  a  neck  tapering  upwards." 

That  the  action  which  arises  between  the  metal  and  the  acid  is 
due  to  polarization  is  evidenced  by  the  following  proceeding:  ''A 
similar  piece  of  copper  wire,  wholly  submerged  in  the  acid,  so  as  to 
entirely  exclude  any  portion  of  the  metal  from  coming  in  contact 


THE    TEETH  AXD    THEIR   DISEASES.  263 

with  the  air,  has  remained  for  many  months  without  imparting;  the 
sHghtest  tinge  of  color  to  the  liquid ;  but  on  suffering  the  fluid  to 
evaporate,  so  as  to  bring  the  upper  end  of  the  metal  near  to  its 
surface,  the  instant  the  slightest  portion  becomes  exposed  to  the 
atmosphere  chemical  action  immediately  commences."  There  is 
thus,  where  no  sufficient  normal  affinity  exists  between  the  metal  and 
the  liquid  to  effect  the  decomposition  of  water,  a  power  imparted,  by 
the  metal  being  polarized  by  the  atmosphere,  which  renders  it  then 
capable  of  accomplishing  it. 

"  The  atmosphere,"  says  Mr.  Bridgman,  "  in  its  normal  state  being 
electro-positive,  renders,  by  a  well-known  law  of  induction,  bodies 
opposed  to  it  electro-negative.  The  exposed  end  of  the  cojiper  is, 
therefore,  thus  rendered  electro-negative,  and  the  acid,  by  the  same 
rule,  being  electro-negative  also,  the  immersed  end  of  the  metal  be- 
comes electro-positive.  It  is  an  established  rule  that  bodies  to  be 
electro-decomposed  must  first  be  rendered  electro-positive;  and  it 
is  also  a  part  of  the  same  rule  that  bodies  receiving  an  addition  of 
matter  must  first  be  made  electro-negative.  Hence  the  exposed  end  of 
the  metal  has  become  negative  and  received  the  crystallization,  while 
the  immersed  portion,  being  positive,  has  been  acted  upon  accordingly. 

"The  appearance,  however,  of  the  crystallization  upon  what  was 
at  first  the  dry  end  of  the  metal  requires  particular  attention.  It  is 
one  of  the  special  effects  of  electrolytic  action  that  fluids  pass  to,  and 
accumulate  at,  the  negative  pole.  Obeying  this  law,  the  acid  imme- 
diately begins  to  ascend  and  spread  itself  over  the  surface  of  the 
unimmersed  end  of  the  metal.  But  now  we  have  another  special 
provision,  which  demands  the  most  careful  and  attentive  considera- 
tion, as  it  constitutes  the  first  step  in  the  resulting  chemical  action. 

"One  metal  placed  in  two  dissimilar  fluids,  as  the  air  and  the 
acids,  acquires  the  same  condition  that  two  dissimilar  metals,  or 
one  metal  non-homogeneous,  assume  when  exposed  to  the  air  :  each 
has  become  polarized,  and  rendered  amenable  to  chemical  action. 
Water,  being  a  compound  of  gases  chemically  combined,  can  have 
its  gases  uncombiued  only  by  equal  degree  of  force  being  antago- 
nistic to  them;  and  consequently  the  decomposition  of  water  must 
be  preceded  by  some  other  arrangement.  'Now,  the  atmosphere,  being 
only  a  mixture  of  gases,  or  gases  merely  in  a  state  of  mechanical 
admixture,  which  admits  of  their  being  readily  separated  on  the 
slightest  interference,  supplies  the  initiatory  steps  by  which  de- 
composition can  be  effected. 

"  The  first  immediate  effect  upon  a  polarized  metal  is  to  drive 


264  ORAL  DISEASES  AND   SURGERY. 

the  oxygen  of  the  atmosphere  to  the  positive  end.  Its  combination 
with  the  metal,  in  oxidating  or  rusting  it,  is  a  chemical  action  deter- 
mined by  the  electro-polar  condition  ;  and  it  has  been  established  by 
Faraday  and  others  that  this  chemical  union  is  invariably  accom- 
panied by  a  development  of  electricity,  which  in  its  turn  can  be 
made  to  produce  electro-chemical  results  of  an  equal  degree  in 
another  direction. 

"  The  greater  amount  of  action  taking  place  at  the  neck  of  the 
copper  wire  will  now  be  readily  comprehended.  The  oxygen  of  the 
atmosphere  has  been  driven  toward  the  positive  end  of  the  metal ; 
but  its  progress  has  been  arrested  by  the  acid  surrounding  it.  The 
thin  fibres,  however,  rising  from  its  surface,  being  soon  saturated 
with  the  oxygen,  and  presenting  the  latter  in  its  most  favorable 
form  for  acting  upon  the  metal,  facilitate  its  oxidation,  and  con- 
sequently accelerate  its  solution,  and  render  the  ascending  acid 
saturated  and  ready  for  at  once  becoming  a  crystalline  deposit,  while 
little  or  no  solution  has  been  effected  in  the  acid  below. 

"It  must  be  kept  in  mind  that  an  electric  state  is  not  a  fixity,  but 
is  relative,  and  depending  upon  attendant  circumstances.  Thus,  if 
the  copper  wire  had  been  subsequently  inverted,  the  immersed  end, 
which  is  now  positive,  would  then  have  been  rendered  negative,  and 
vice  versa;  or  had  the  acid  at  any  time  been  filled  up  to  the  top  of 
the  tube,  the  exposed  portion  only,  however  small  that  might  be, 
would  have  remained  negative,  the  surface  of  the  liquid  determining 
the  line  of  demarkation  between  them. 

"Let  us  now  apply  these  facts  to  the  mouth.  The  external  epi- 
thelial layer  of  the  gum  is  constantly  throwing  off  its  worn-out 
cells,  and  by  this  wasting  process  it  determines  its  electro-positive 
state,  while  the  crown  of  the  tooth,  as  a  continuation  of  the  epider- 
mal layer,  partakes  of  the  like  condition.  Were  the  teeth  wholly 
and  constantly  submerged,  and  protected  from  the  air,  it  is  probable 
that,  like  the  copper  wire  beneath  the  acid,  they  too  might  i-emain 
intact.  But  as  the  air  is  constantly  passing  into  the  mouth,  or  even 
through  it  in  the  act  of  breathing,  they  are  thus,  having  one  end 
exposed  to  the  air  and  the  other  to  the  fluid  moistening  the  gum, 
subject  to  the  same  polarizing  influence  as  the  metals. 

"  The  negative  portion  of  the  polarized  tooth  being  represented 
by  the  portion  of  the  wire  exposed  to  the  atmosphere,  it  will  be  at 
once  comprehended  why  tartar  accumulates  upon  certain  parts  only 
of  the  teeth,  and  how  it  is  enabled  to  creep  over  the  surface  and 
adhere  with  tenacity. 


THE   TEETH  AND    THEIR  DISEASES.  265 

"  In  the  case  of  the  partly-submerged  wire  it  has  been  shown  that 
the  principal  amount  of  electro-chemical  action  takes  place  near  the 
surface  of  the  fluid,  this  point  determining  the  line  of  demarkation. 
Hence  in  the  mouth  this  line  may  be  taken  as  the  existing  free  edge 
of  the  gums.  The  moisture  accumulating  here,  in  the  event  of  any 
electro-chemical  action  taking  place,  it  would  necessarily  be  imme- 
diately above  that  line,  and  consequently  the  substance  of  the  tooth 
directly  above  the  gum  would  be  attacked.  We  see  this  actually 
taking  place  in  the  peculiar  decays  so  common  at  the  exterior  or 
anterior  basal  area  of  the  molars,  and  also  on  the  same  part  of  the 
upper  incisors. 

"In  the  interstitial  divisions,  the  moisture  accumulates  between 
the  teeth  by  capillary  attraction,  and  in  connection  with  this  we 
have  approximal  decay  as  one  of  the  commonest  forms  occurring. 
The  oxygen  is  attracted  to  the  part,  and  produces  the  acid  so  in- 
variably present,  while,  by  electrolysis,  the  lime  is  abstracted  and 
removed  to  another  part,  or  carried  away  in  solution.  By  such 
electrolysis,"  Mr.  Bridgman  thinks,  "every  other  phase  and  phe- 
nomenon of  decay  is  to  be  traced  and  explained." 

Yiewing  the  matter  strictly  from  the  standpoint  of  a  chemist,  our 
author  has  overlooked  vital  resistive  force.  We  trust  we  have, 
however,  completed  this  portion  of  his  subject  for  him,  and  thus 
afforded  him  a  required  support  in  the  chemico-vital  aspect  of  his 
subject  in  which  his  foundation  seems  lacking. 

We  may  here  follow  Mr.  Bridgman  in  his  consideration  of  filling- 
materials. 

"In  a  prize  essay,"  he  says,  "I  have  shown  that  an  amalgam 
filling  in  the  side  of  a  tooth  having  one  edge  near  the  gum  generates 
acid  at  the  latter  point.  This  is  due  to  polarization.  A  body  of 
metal  having  its  two  ends  or  opposite  sides  exposed,  under  different 
circumstances,  becomes  polar,  and  in  proportion  as  there  is  any 
substance  to  be  acted  upon  by  oxygen,  so  is  the  amount  of  chemical 
action  regulated.  Thus,  a  metallic  plug  in  an  approximal  cavity, 
or  in  the  external  basal  area  of  the  molars,  will  have  the  cervical 
edge  continually  wet,  while  the  upper  part  may  be  comparatively 
dry;  and  hence  will  be  assumed  the  two  conditions  as  represented  by 
the  intermediate  and  exposed  portion  of  the  wire.  It  has  often  been 
lamented  that,  however  carefully  and  well  these  fillings  may  have 
been  done,  there  is  the  ever-recurring  annoyance  of  finding,  in  a  few 
years  at  the  most,  and  not  unfrequently  in  a  few  months,  that  the 
sides  of  the  plugs  and  baso-caval  surface  have  become  defective  ; 


266  ORAL  DISEASES  AND  SURGERY. 

showing  that,  although  all  the  defects  may  have  been  removed  in 
the  first  instance,  the  cause  has  been  retained. 

"With  the  entire  range  of  metals  and  metallic  compounds,  it  maj 
be  taken  as  a  fact  that  from  gold  to  copper  and  zinc  it  is  only  a 
question  of  degree,  for  the  one  cause  affects  them  all  more  or  less. 
In  respect  to  this,  gold  is  unquestionably  the  best  by  very  far,  as 
being  one  of  the  least  oxidizable  ;  but  even  with  this,  certain  pre- 
cautions are  essential  to  success.  The  one  indispensable  condition 
is  that  there  shall  he  no  lodgment  for  moisture  at  any  point  of  its 
circumference.  The  edge  of  the  plug  must  be  made  as  perfect  as 
possible,  and  no  fissures  communicating  with  it  may  be  suffered  to 
remain ;  for,  if  there  be,  electro-chemical  action  will  be  certain  to 
recommence. 

"With  amalgams,  this  precaution  is,  if  possible,  even  more  impor- 
tant ;  but  with  these  there  are  other  points  requiring  attention.  The 
composition  of  amalgams  is  a  subject  which  has  never  yet  been 
systematicall}'^  investigated,  and  those  now  in  use  differ  considerably 
in  character. 

"  Zinc  and  copper,  and  their  various  alloys,  with  tin  and  silver,  etc., 
form  the  hardest  amalgams ;  while  gold,  silver,  palladium,  and  pla- 
tinum form  only  imperfect  amalgams,  which  never  acquire  sufficient 
hardness  to  resist  friction.  In  the  latter,  too,  the  mercury  readily 
oxidizes  and  produces  discoloration,  while  some  of  the  former  pass 
very  quickly  from  oxidation  to  the  acidifj'ing  stage,  and  thus  soon 
reproduce  the  electro-chemical  destruction  of  the  dentine. 

"There  is  another  and  more  serious  objection  still  to  be  urged 
against  some  of  the  more  modern  preparations.  Amalgams  hard- 
ening imder  a  state  of  polarization  assume,  in  some  cases,  a  peculiar 
surface-crystallization,  but  almost  invariably  possess  coarser  crystals. 

"I  have  exhibited,"  says  Mr.  Bridgman,  "two  pieces  of  zinc  which 
had  been  amalgamated  and  suffered  to  harden, — one  under  polariza- 
tion, the  other  without  it.  With  the  polarized  surface  the  metal 
had  acquired  a  considerable  amount  of  crystallization  of  a  peculiar 
character,  projecting  above  the  level  of  its  surface,  together  with  a 
somewhat  coarsely  crystalline  texture  without ;  while  that  which 
had  been  allowed  to  harden  withput  being  polarized  was  much 
finer  in  texture,  although  distinctly  crystalline.  Two  pieces  of 
amalgam,  treated  in  a  similar  manner,  showed  the  same  correspond- 
ing results.  In  addition,  both  the  polarized  metals  exhibited  more 
discoloration  than  the  unpolarized  ones,  and  all  showed  that  amount 
of  roughness  inconsistent  with  a  perfect  filling." 


THE    TEETH  AND    THEIR   DISEASES.  267 

Having-  thus  traced  the  defects  of  metallic  fillings,  Mr.  Bridgman 
proceeds  to  consider  whether  the  objections  are  insuperable. 

"  There  are  two  proceedings  indicated,"  he  remarks,  "  as  being 
desirable.  The  one  is  to  prevent  polarization  ;  the  other,  to  prevent 
the  effects  of  polarization  being  reflected  upon  the  dentine.  The  former 
is  not  by  any  means  difficult,  but  it  requires  a  thorough  knowledge 
of  the  laws  under  which  it  takes  place  to  adopt  the  provisions  under 
all  the  different  circumstances  required.  Insulation,  however,  is  one 
of  the  means  to  be  secured.  This,  too,  is  the  end  to  be  sought  in 
protecting  the  dentine.  Either  gutta-percha,  waxed  tissue-paper, 
or  allotropic  sulphur — but,  above  all,  the  so-called  os-stopping — 
forms  an  admirable  lining  for  a  cavity,  where  little  success 'could  be 
hoped  for  from  an  unprotected  amalgam.  It  also  compensates  for 
the  want  of  fineness  in  the  texture  of  the  metal." 

There  is  another  point  in  connection  with  the  electro-chemical 
action  of  metals  upon  the  teeth  discussed  in  the  paper  under  consid- 
eration. "Wherever  a  gold  band  comes  in  contact  with  the  exposed 
dentine  of  a  tooth,  injury  is  commonly  seen  to  ensue,  and  decay 
supervenes  if  the  touched  part  be  near  the  gum.  This  is  assumed 
to  be  fully  explained  in  the  experiment  with  the  copper  wire.  "The 
gold,"  says  Mr.  Bridgman,  "  may  touch  any  part  represented  by  the 
blue  sulphate,  but  at  the  intermediate  portion — that  is,  that  portion 
of  the  tooth  just  above  the  margin  of  the  gum — it  is  fatal." 

Criticism  on  these  deductions  is  anticipated  in  a  recognition  of 
the  fact  that  the  author  considers  special  cases  alone,  and  does  not 
lay  down  a  general  rule.  That  he  fairly  exposes  the  condition  of 
many  mouths  seems  entirely  beyond  doubt ;  and  it  must  be  ad- 
mitted that  he  has  given  a  very  satisfactory  expression  to  the 
chemical  aspect  of  the  subject  of  dental  caries.  (See  Denuda- 
tion.) 

Medicines  and  Articles  of  Food. — That  medicines,  even  the  nitro- 
muriatic  acid  so  frequently  prescribed  as  an  hepatic  alterative,  and 
the  muriated  tincture  of  iron  used  by  almost  every  practitioner  as  a 
tonic,  are  not  such  sources  of  offense  to  the  dental  organs  as  is  gen- 
erally inferred,  the  author  has  come  to  be  reasonably  well  satisfied 
Prescribing  both  combinations  with  much  frequency  in  his  clinic  as 
well  as  private  practice,  he  founds  this  conclusion  on  an  extent  of 
observation  that  would  seem  to  render  it  entirely  reliable.  Not  that 
the  careless  employment  of  such  medicines  is  at  all  to  be  com- 
mended ;  but  the  inference  is  meant  to  be  conveyed  that  caries 
associated  with   the   periods   of    such    prescriptions   has   explana- 


268  ORAL  DISEASES  AND  SURGERY. 

tion  in  the  conditions  prescribed  for,  ratiier  than  in  the  medicines 
prescribed. 

Acids  are  not  best  given  through  glass  tubes,  but,  being  sufficiently 
diluted,  the  draught,  if  such  care  be  thought  necessary,  may  be 
thrown  into  the  back  part  of  the  mouth,  and  swallowed  in  a  single 
muscular  act,  after  which  the  mouth  may  be  rinsed  with  water 
rendered  slightly  alkaline  by  the  addition  of  a  few  drops  of  liquor 
ammoniae.  The  system,  however,  which  demands  an  acid  medi- 
cation will  seldom  find  its  dental  organs  injured  by  the  reception 
of  a  share.  Chalk,  in  place  of  the  ammonia  water,  is  suggested  by 
Dr.  J.  D.  White,  he  asserting  that  in  this  article  acid  medicaments 
find  their  quickest  and  most  reliable  neutralization. 

Mercury,  as  a  medicine,  has  no  direct  efiect  on  the  teeth, — its 
action  having  an  intermediate  signification;  neither  have  any  of  the 
potash  preparations  as  ordinarily  administered. 

Sugar. — As  usually  employed,  sugar  is  not  to  be  considered  an 
agent  deleterious  to  the  teeth,  as  locally  it  can  only  act  through 
its  conversion  into  acetous  acid.  A  too  free  use  of  the  agent,  how- 
ever, by  debilitating  the  digestive  functions,  indirectly  affects  these 
organs,  in  common  with  all  other  parts,  by  diminishing  the  resistive 
force, — in  other  words,  through  malnutrition. 

Yinegar,  lemon-juice,  the  malic  acid  of  apples,  the  tartaric  of 
grapes,  will,  all  of  them,  in  varying  extent,  decompose  tooth-struc- 
ture through  affinity  for  the  lime.  When,  however,  their  action  is 
thus  iujm'ious,  the  fact  is  easily  recognizable  by  the  patient  in  the 
loss  of  that  polish  noticeable  on  touching  the  organs  with  the  tip  of 
the  tongue  ;  or  in  the  presence  of  the  feeling  which  is  described  by 
the  expression,  familiar  to  every  person,  of  "  the  teeth  being  on 
edge." 

It  is  not,  however,  to  be  affirmed  or  maintained  that  any  of  these 
articles,  when  brought  in  contact  with  the  teeth  under  the  circum- 
stances of  mastication,  with  their  speedy  dilution  by  the  oral  fluids 
— always  proportioned  to  requirements — are  sources  of  disease  to 
the  parts.  Prudence  in  the  use  of  such  things  is,  nevertheless,  to  be 
recommended  to  every  person  having  teeth  of  loose  structure, — soft, 
chalky  teeth. 

Of  the  dried  fruits,  raisins  may,  it  seems  to  the  author,  be  with 
most  reason  denied  ;  they  do  without  doubt  rapidly  corrode  the  teeth, 
and  are  most  tenacious  in  their  lodgment.  That  it  is  necessary  to 
proscribe  their  use,  except  in  the  case  of  children,  is,  however,  at 
least  debatable. 


THE    TEETH  AND    THEIR   DISEASES.  269 

The  spiritus  nitri  dulcis, — a  compound  of  the  nitrate  and  carbonate 
of  potassa,  sulphuric  acid,  and  alcohol, — freely  used  in  the  United 
States  as  a  febrifuge,  particularly  with  children,  is  credited  with 
being  a  frequent  cause  of  dental  caries  ;  the  diluted  state  in  which 
the  medicine  is  always  administered,  however,  may  lead  this  infer- 
»         ence  to  be  received  cum  grano  salis. 

Condition  5.  The  Absence  of  Mechanical  Destriictives,  as  sali- 
vary calculi,  the  bands  of  artificial  denture,  etc.  See  chapters  on 
Salivary  Calculus,  and  Dentures. 

Condition  6.  Accidental  Influences. — Under  the  sixth  head 
reference  may  first  be  made  to  what  may  be  termed  the  gymnastics 
of  the  teeth.  These  organs,  like  all  others  of  the  body,  require  to  be 
used,  and,  when  denied  the  exercise  of  their  function,  deterioration 
universally  follows.  Illustration  of  this  is  markedly  exhibited  in 
slop-fed  cows,  the  teeth  refused  their  accustomed  task  quickly  be- 
coming carious  and  loosened  ;  also  in  the  case  of  persons  using  alone 
one  particular  side  of  the  dental  arch, — the  unused  organs  being  soon 
enveloped  in  tartarized  debris,  and  the  gums  becoming  turgid  and 
debased.  This  debasement  is  shown  also  in  those  who  live  on  food 
which  demands  but  little  trituration. 

The  practice  indulged  in  by  many  persons  of  breaking  the  harder 
shell  nuts  with  the  teeth  is  most  reprehensible,  cracking  and  splitting 
the  enamel,  and  thus  exposing  the  more  susceptible  underlying  den- 
tine,— or,  even  where  such  accidents  do  not  occur,  exciting  through 
shock  a  species  of  chronic  inflammation  which  lowers  the  resistive 
force  of  the  tooth. 

"  Dental  operations,"  as  remarked  by  Dr.  J.  Taft  in  his  work  on 
"Operative  Dentistry,"  "performed  at  an  improper  time  and  in  an 
improper  manner,  the  vitality  of  the  teeth  being  thus  impaired,  or  a 
diseased  condition  being  established,  are  to  be  esteemed  as  exciting 
causes  of  caries.  Often  from  improper  use  of  the  file  extensive 
inflammation  of  the  dentine  supervenes,  which  is  sometimes  fol- 
lowed by  death  of  the  tooth  and  by  disease  of  the  contiguous  parts." 
Another  cause  enumerated  in  this  volume  is  "  sudden  transition  from 
one  extreme  of  temperature  to  another." 

The  employment  of  a  variety  of  metals,  as  fillings,  is  objection- 
able. Particularly  is  it  the  case  that  amalgam  and  gold  should 
not  be  used  in  conjunction.  I  think  it  will  be  found  an  exception 
where  a  healthy  denture  can  be  exhibited  having  these  two  articles 


270  ORAL  DISEASES  AND   SURGERY. 

promiscuously  related.  This  stricture  also  applies  to  the  case  of 
gold  plates  much  alloyed  with  the  meaner  metals,  as  with  silver  or 
copper,  particularly  the  latter. 

Cleanliness  is  an  essential  to  a  healthy  denture.  Teeth  should 
be  cleansed  after  every  meal ;  to  this  end  a  tooth-pick — always  to 
be  made  of  wood — is  to  be  passed  through  the  interspaces,  and  the 
mouth  afterwards  rinsed  with  water,  or  water  to  which  have  been 
added  a  few  drops  of  alcohol  or  cologne.  As  a  dentifrice,  to  be  used 
when  required, — which  will,  most  likely,  be  once  each  day  at  least, 
— the  following  combination  may  be  employed  : 

R. — Ossis  sepiae  pulveris,  5ss; 
Cret£e  praeparatte,  Jij  '> 
Coralli  albi  pulveris,  3ss; 
Iridis  Florentinae  pulveris,  ^j  ; 
Carbonis  ligni  pulveris,  5j ; 
Lapidis  pumicei  pulveris,  oU  ; 
Olei  limonis,  q.  s. 

In  a  mouth  self-cleansing,  however,  where  there  is  little  tendency 
to  the  accumulation  and  retention  of  debris,  it  would  not,  of  course, 
be  found  necessary  to  have  such  excess  of  cutting  ingredients.  A 
modification  of  the  prescription  might  therefore  be  made  : 

R. — Cretae  prseparata^,  S'j ; 
Ossis  sepiae  pulveris,  5ss; 
Iridis  Florentinae  pulveris,  3j ; 
Cinchonte  rubrae  pulveris,  5j ; 
Saponis  albi  pulveris,  5'j-     M. 

In  the  treatment  of  any  case  of  dental  caries  which  may  present 
itself,  the  careful  practitioner  first  endeavors  to  satisfy  himself  of 
the  causes,  constitutional  and  local,  influencing  the  diseased  condi- 
tion;  of  the  constitutional  causes,  all,  as  must  be  inferred,  aifect  the 
integrity  of  the  teeth  which  are  deteriorative  to  the  system  at  large. 
Unhappily  for  the  denial  organism,  primary  unhealthy  impressions 
made  upon  the  teeth,  while  in  their  formative  or  pulpy  state,  are 
apt  to  influence  more  or  less  their  character  for  life,  just  as  certain  of 
the  exanthemata, — variola,  for  instance, — occurring  at  this  period, 
are  so  apt  to  impress  permanent  pittings  upon  the  enamel. 

Unhealthy  parents,  as  has  been  suggested,  cannot  possibly  beget 


THE    TEETH  AND    THEIR  DISEASES.  271 

healthy  offspring.  Here  is  a  great  primary  antagonism.  The 
teeth,  however,  are  living  and,  consequently,  changing  bodies  :  par- 
ticularly is  this  true,  physiologically,  of  young  teeth.  Constitutional 
treatment  may  thus  do  service  even  as  every  molecule  of  tooth- 
structure  is  concerned.  Such  treatment  would  of  course  be  longer 
in  receiving  apparent  response,  as  must  be  evident  upon  considering 
the  relative  low  vitality  of  these  organs,  than  treatment  directed  to 
the  production  of  an  impression  on  the  soft  parts,  or  on  common 
bone ;  yet,  because  a  tooth  is  an  organized  body,  because  it  has 
innervation  and  circulation,  such  treatment,  to  a  greater  or  less 
extent,  must  have  its  influence. 

A  first  indication  calls,  therefore,  for  the  consideration  of  causes 
interfering  with  the  proper  vitality  of  any  denture  coming  under 
observation.  Whether  deteriorated  hereditarily  or  otherwise,  duty 
to  the  patient  demands  such  consideration  of  the  case. 

We  will  suppose  a  trouble  to  be  hereditary.  Here,  if  we  can  find 
in  a  patient  the  observable  existence  or  continuance  of  habits  of 
functional  irregularity,  or  of  animal  habits  common  to  the  parent 
and  which  are  to  be  esteemed  of  deteriorating  import,  our  first  atten- 
tion is  to  be  directed  to  a  correction.  The  parent  may  have  been 
specifically  diseased,  let  us  suppose,  by  his  parent,  and  thus  the  bad 
teeth  of  both  father  and  child  lie  in  a  venereal  molecular  impression. 
Here  a  predisposing  cause  would  have  come  from  and  would  be  still 
residing  in  the  transmitted  condition.  Granting,  then,  that  such  mole- 
cules, still  living,  are  impressible,  would  not  judgment  direct  a  pri- 
mary treatment  to  the  production  of  an  impression  in  such  direction  ? 
I  have  treated  many  a  child,  for  skin-  and  other  diseases,  where  the 
affliction  was  a  true  hereditary  venereal  transmission,  and  I  never 
thought  of  directing  medication  otherwise  than  in  recognition  of 
such  a  transmission;  and  satisfied,  as  every  medical  man  must  be, 
that  the  circulatory  fluid  permeates  tooth-structure,  I  treat  vene- 
really  deteriorated  teeth  on  a  common  principle,  and  have  found  in 
the  result  that  measure  of  success  which  has  justified  the  conclu- 
sions. In  other  words,  I  have  prolonged  the  life  and  health  of  such 
organs,  just  as  are  prolonged  the  life  and  health  of  the  patient  upon 
whose  molecules  is  impressed  the  fiat  of  the  tubercles  of  phthisis. 
Such  a  treatment  consists,  however,  not  necessarily  in  administer- 
ing specific  or  supposed  specific  remedies,  but  in  viewing  the  system 
as  laboring  under  depressing  influences,  either  of  a  general  or  special 
local  signification.     This  fact  it  is  most  important  to  recognize. 

A  child,  as  we  have  studied,  may  have  its  molecules  deteriorated 


272  ORAL   DISEASES  AND   SURGERY. 

by  a  transmitted  mercurial  impression,  or  a  parent  may  have  been 
an  inebriate,  and  thus  have  debased  his  child  in  himself.  The 
results  of  an  excessive  venery  may  have  been  transmitted.  A 
mother,  from  lack  of  nourishing  material,  may  have  degenerated  her 
offspring.  These  causes  of  transmitted  ills,  the  appreciable  ones,  I 
may  say,  are  many  :  all  must  recognize  them. 

Improper  diet  to  the  developing  child,  as  we  have  so  fully  studied, 
is  plainly  enough  a  cause  of  bad  teeth.  The  state  of  health  of  such 
a  developing  child  has  its  influence ;  indeed,  so  marked  is  this,  that 
by  an  observation  of  teeth  belonging  to  the  various  periods  of  life, 
one  can  easily  trace  constitutional  variations  ;  for  just  as  at  different 
periods  the  functions  of  organic  life  were  healthily  or  unhealthily 
performed,  so  we  find  the  disturbances  written  in  the  character  of 
the  teeth  belonging  to  the  period.  More  expressive  even  than  this 
is  the  fact  that  the  deciduous  teeth  mark,  in  the  progress  of  their 
development,  the  health  of  the  mother. 

That  the  teeth,  in  their  formative  state,  partake  of  the  healthy  or 
unhealthy  condition  of  the  system  at  large,  all  observers  admit. 
But  here,  unfortunately,  the  matter  has  been  left,  most  practitioners 
acting  on  the  premise  that  such  impressions  are  never  to  be  altered. 
At  such  a  conclusion  it  is  impossible  not  to  express  surprise.  Who, 
in  his  own  person  or  in  the  persons  of  friends,  has  not  remarked  the 
varying  conditions  of  the  health  of  the  teeth  ?  Up  to  the  age  of 
sixteen  I  was  myself  a  martyr  to  toothache  ;  yet  about  that  period 
a  change  occurred,  since  which  time  I  have  had  no  trouble.  Is  it 
suggested  that  the  teeth  may  have  been  filled  ?  True,  they  have 
been;  but  certain  of  the  fillings  came  out  years  ago,  and  have  never 
been  replaced,  yet  the  teeth  are  quite  as  good  as  those  in  which 
the  operations  remain. 

Similar  instances  exist  in  profusion,  and  yet  the  lesson  seems 
unheeded.  There  is  a  constitutional  treatment  for  the  carious  tooth, 
as  there  is  for  the  carious  maxilla,  and  from  a  common  standpoint 
are  the  diseases  of  both  to  be  viewed.  It  is  not,  of  course,  every 
case  of  a  carious  bone  that  demands  systemic  treatment,  neither 
is  it  so  with  the  teeth  ;  the  source  of  offense  in  the  one,  as  in  the 
other,  may  be  strictly,  local  in  its  character ;  but  ill  success  must 
ever  attend  that  practitioner  who  has  not  the  inclination  to  look  for  a 
primary  lesion  outside  of  things  strictly  local  in  signification. 

Resume. — Integrity  of  the  teeth  depends  on  two  general  con- 
ditions :  inherent  vital  resistive  power,  and  the  absence  of  irritating 


THE   TEETH  AND    THEITt  DISEASES.  273 

influences.  A  tooth  may,  in  its  vital  relations,  be  just  strong 
enough  to  resist  external  forces  brought  to  bear  against  it,  if  in  its 
construction  there  is  no  mechanical  imperfection.  It  may,  even 
with  imperfections,  be  able  to  resist  temporary  injurious  impres- 
sions. The  vitality  of  a  tooth  can  be  elevated  as  the  vitality  of 
a  lung  is  increased.  The  study  of  the  vitality  of  a  tooth,  and  the 
study  of  its  adverse  influences,  is  the  study  of  vitality  and  the  ex- 
pression of  irritation  anywhere.  The  treatment  of  dental  caries  is 
both  medicinal  and  operative. 


18 


CHAPTER   XI. 

THE  LOCAL   TREATMENT   OF   DENTAL   CARIES. 

Caries  of  a  tooth  differs  surgically  from  caries  of  bone  proper  in 
the  fact  of  a  too  common  inability  to  repair  by  any  efl'ort  of  nature 
the  injury  done  through  the  destructive  influences  of  the  disease. 
Not  but  what  such  repair  is  attempted,  and  indeed  oftentimes  suc- 
cessfully accomplished,  as  witnessed  in  tubular  consolidation,  where 
power  sufficient  exists  to  perfect  the  attempt,  as  seen  in  the  process 
generally  spoken  of  as  vitrifaction  or  eburnification,  a  mode  of  natural 
cure  and  resistance  which  no  mechanical  operation,  however  success- 
fully performed,  can  equal.  This  process  of  secondary  calcification,  or 
eburnification,  exhibits  fully  the  inflammatory  phenomena  associated 
with  dental  caries,  for  not  otherwise  than  as  circulatory  expressions 
is  it  possible  to  explain  the  phenomena:  it  is,  in  every  particular, 
a  modified  repetition  of  the  ordinary  lymph  exudation  and  circum- 
vallation  seen  in  abscess,  either  of  bone  or  soft  parts. 

A  tooth  attacked  in  any  part  by  caries  expresses  the  stages  and 
steps  of  the  inflammatory  process,  inasmuch  as  at  the  first  attack 
of  the  disturbing  agent  immediate  alteration  occurs  in  the  circula- 
tion or  nutrition  of  the  part,  the  tubules  being  filled  up  and  solidi- 
fied, or  the  attempt  made,  by  deposit  of  adventitious  matter,  the 
disease  being  thus  resisted  and  retarded ;  conquering  only  when  the 
attacking  agent  is  stronger  than  the  vital  force  which  combats  it. 

Such  phenomena  express  to  the  observing  mind  the  principles  of 
the  treatment  of  dental  caries,  i.e.  to  relieve  the  part  from  the  agent 
of  offense,  and  to  strengthen  the  resistive  ability. 

Passing  from  the  first  of  these  principles,  which  has  been  con- 
sidered on  preceding  pages  with  perhaps  quite  sufficient  fullness,  we 
proceed  to  the  discussion  of  the  second. 

A  tooth  attacked  at  a  given  point  by  irritating  agencies  will, 

step  by  step,  break  and  give  way  before  the  irritant ;  or,  otherwise, 

will  resist  and  antagonize.      Resistance  implies  assistance,  which 

assistance  may  be  either  of  nature  or  of  art,  or  of  both.     What- 

(274) 


LOCAL    TREATMENT  OF  DEXTAL    CARIES.        275 


ever  shall  tend  so  to  consolidate  or  protect  the  parietes  of  a  cavity 
as  to  render  the  parts  impervious  and  insusceptible  to  external  agents, 
will  save  the  tooth.  Such  result  is  aimed  to  be  secured  through 
the  removal  of  dead  and  dying  dentine  from  a  cavity,  and  provoca- 
tion to  tubular  consolidation  through  the  introduction  of  an  agent 
exciting  to  the  vascular  system  of  the  tooth  ;  the  chloride  of  zinc 
being  among  the  best  of  such  agents,  and  most  conveniently  em- 
ployed in  the  preparation  known  as  oxychloride.  (See  Filling  Teeth.) 
Zinc  so  introduced  into  a  tooth  will  not  unfrequently  be  found  fol- 
lowed by  such  iuflammatory  consolidation  that  a  cavity  from  being 
soft  and  of  loose  structure  is  seen  to  become  solid  and  dense  to  an 
extent  that  makes  it  entirely  self-protecting;  it  has  become  glass-like,^- 
in  hardness :  this  occurs,  however,  only  where  the  vital  force  is  abj 
to  respond  to  the  excitation.  The  practitioner,  aware  of  this  met, 
directs  a  medication  to  the  assistance  of  an  asthenic  system  laboring 
under  advancing  dental  caries,  precisely  as,  under  similar  circum- 
stances, he  endeavors  to  assist  nature  in  caries  of  bone  proper. 
In  the  one  case  as  in  the  other,  thus  only  may  he  expect  to  get 
a  cure.  Such  principle  of  treatment  is  so  in  accordance  with  the 
exhibitions  of  nature's  expression,  that  no  medically  educated  ex- 
perience may  doubt  the  indications. 

The  cure  of  caries  by  61ing  finds  its  explanation  precisely  as  ex- 
pressed in  the  employment  of  the  zinc.  The  file  cutting  away  the 
weak  point,  and  exciting,  through  the  exposure  of  the  dentine,  in- 
creased vascularity,  structural  consolidation  results,  and  thus  external 
or  offending  agents  are  shut  out,  precisely  on  the  same  principle  as  a 
ball  may  become  encysted  in  a  bone  and  remain  for  years  innocuous. 

Gold  or  other  ordinary  agents  employed  in  filling  act  to  an 
extent  in  the  same  way:  these,  however,  being  commonly  non- 
irritating  or  exciting,  are  not  apt  to  be  found  associated  with  the 
same  extent  of  change  ;  in  all  reasonably  vital  teeth,  how- 
ever, are  to  be  seen  such  attempts  at  resistance.  A  fill- 
ing of  metal  represents,  and,  to  a  degree,  stands  in  place 
of,  the  tubular  or  structural  consolidation. 

rig.  61  represents  a  section  of  carious  tooth  from  life, 
exhibiting  structural  consolidation.      In  this  particular 
case,  although  the  cavity — being  in  a  lower  molar  tooth 
— was  large  enough  to  contain  a  pea,  caries  was  held  completely  in 
abeyance,  and  had  been  so  for  years,  the  parietes  of  the  cavity  being 
as  hard  as  flint. 

In  the  local  treatment  of  ^dental  caries,  three  indications  exist: 


Fig.  G1. 


276  ORAL  DISEASES  AND   SUBGERY. 

'  1.  Neutralization  of  the  oral  fluids  and  the  induction  of  a  state 
of  general  health  in  the  mouth. 

2.  Medical  treatment  of  the  tooth, 

3.  Mechanical  treatment  of  the  cavity. 

1.  The  normal  condition  of  the  oral  fluids  is  neutral.  A  healthy- 
saliva,  in  which  practically  is  included  the  secretion  of  the  mucous 
glands,  as  well  as  that  brought  into  the  mouth  by  the  ductus  sali- 
varii,  is  an  inodorous,  tasteless,  slightly  viscid  fluid,  bland,  unirri- 
tating,  subject  to  changes  as  influenced  by  physiological  impressions, 
aff'ording  at  times  an  alkaline  reaction,  again  being  temporarily 
acid,  sometimes  sweet,  and  often,  under  the  impressions  of  dry 
bodies,  mucilaginous  to  a  marked  extent,  owing  this  last  character- 
istic to  excess  of  mucus,  a  substance  almost  analogous  to  vegetable 
mucilage,  having  as  a  chief  constituent  an  albuminoid  compound, 
with  the  oflice  of  preserving  the  membranes  moist  and  in  a  condi- 
tion fitted  to  the  performance  of  their  functtions.* 

*  Messrs.  Griffith  and  Henfrey,  the  able  editors  of  the  "  Micrographic  Dic- 
tionary," state,  when  speaking  of  the  oral  cavity  :  "  The  mucous  liquid  of  the 
mouth  contains,  in  addition  to  detached  epithelial  cells,  very  transparent  cor- 
puscles about  1-2000  to  1-1500^'  in  diameter,  consisting  of  a  delicate  cell-wall,  a 
nucleus,  with  a  number  of  minute  moving  molecules.  We  have  figured  these 
among  the  test  objects.  (Plate  I.,  Fig.  5.)  They  are  called  mucous  or  sali- 
vary corpuscles.  KoUiker  regards  them  as  a  form  of  exudation  corpuscles ; 
and  this  view  is  probably  correct,  for  they  may  occur  in  the  secretion  of  any 
mucous  surface  and  have  no  special  connection  with  the  salivary  glands ;  we 
have  found  them  in  myriads  in  the  urine." 

Dr.  Joseph  G-.  Richardson,  of  this  citj'.  Lecturer  on  Pathological  Anatomy 
in  the  University  of  Pennsylvania,  claims,  however,  to  be  the  first  to  demon- 
strate their  true  nature  and  origin,  viz.,  that  they  are  simply  "migrating" 
white  blood-corpuscles,  which  have  become  distended  by  the  endosmosis  of  a 
fluid  less  dense  than  the  liquor  sanguinis.  He  remarks,  "  From  my  experi- 
ments as  detailed  in  the  same  article,  page  253,  and  briefly  described  on  page 
157  of  this  chapter,  I  condlude  that  'tracing  now  the  white  blood-corpus- 
cle from  its  condition  of  irregular  outline  and  amcebaform  movement,  as  ob- 
served in  serum  and  in  heavy  urine,  when  the  circumambient  fluid  approaches 
the  density  of  1028,  through  its  rounded  form,  with  slightly  more  distinct 
nuclei,  in  the  liquor  puris  and  in  urine  of  lower  specific  gravity,  we  find 
that  immersed  in  a  rarer  liquid  approximating  to  the  mean  density  of  the  saliva 
(1005),  it  has  an  accurately  spherical  outline,  is  more  than  twice  the  magni- 
tude, and  contains  a  number  of  minute  actively-moving  molecules,  thus 
exactly  resembling  in  all  sensible  characters  the  true  salivary  corpuscles  ;  and 
it  therefore  seems  reasonably  certain  that  the  blood,  under  the  appointed 


LOCAL    TREATMENT   OF  DENTAL    CARIES.        277 

The  analysis  of  the  fluids  bathing  the  teeth  is  to  precede  opera- 
tions upon  these  organs.  As  acidity  or  alkalinity  is  concerned,  such 
analysis  is  most  easily  made — demanding  but  a  few  days — by  fur- 
nishing the  patient  with  two  strips  of  test-paper, — litmus,  as  it  is 
called ;  paper  colored  with  the  dye  of  the  plant  Lichen  roccella, — 


nervous  influence,  congesting  the  buccal  mucous  membrane  and  associated 
glands,  moves  slowly  enough  through  their  capillaries  to  allow  some  of  its 
white  globules  to  penetrate  the  walls  of  the  vessels,  as  they  do  those  of  the 
frog's  mesentery  in  Cohnheim's  experiment  [Virchow^s  Archiv,  Band  xl.,  S. 
38  et  seq.),  which,  under  the  influence  of  the  rarer  saliva  expanding  them  and 
setting  free  to  move  their  contained  molecules,  constitute  the  bodies  so  long 
known  to  histologists  as  the  corpuscles  of  the  salivary  fluid."  [Vide  Hand- 
book of  Medical  Microscopy,  p.  1G5.)  The  demonstration  by  Dr.  Richardson 
is  as  follows:  "Placing  a  drop  of  blood  from  the  tip  of  my  finger,"  says 
Dr.  E..,  "  upon  a  growing  slide"  (see  Pennsylvania  Hospital  Ptoports,  1869), 
"  I  covered  it  with  a  thin  glass  and  placed  it  upon  the  stage  of  the  microscope. 
After  finding  a  white  blood-corpuscle  showing  well-marked  granules,  I 
raised  the  objective  and  arranged  a  fine  filament  of  thread  from  the  reservoir 
filled  with  fresh  water  to  the  upper  edge  of  the  cover,  and  a  fragment  of  wet 
paper  to  the  lower,  according  to  the  usual  method  for  securing  a  constant 
current  beneath  the  thin  glass.  On  depressing  the  body  of  the  instrument 
and  bringing  the  corpuscle  again  into  view,  I  found  it  still  adhering  to  the 
surface  of  the  cover,  notwithstanding  the  torrent  of  red  globules  hurrying 
over  the  field  ;  and  as  these  became  paler  and  less  distinct  by  reason  of  the 
diminished  density  of  the  serum,  the  white  cell  first  gradually  expanded  and 
displayed  its  delicate  wall  with  two  rounded  nuclei,  then,  after  acquiring  the 
magnitude  of  about  xtVo*^  °^  ^^  inch,  it  exhibited  the  rapid  and  incessant 
movement  of  its  contained  molecules,  and,  finally,  when  its  diameter  reached 
about  the  y^ooth  oi  an  inch,  it  burst  suddenly,  discharging  a  portion  of  its 
contents,  whose  outbreak  resembled  that  of  a  swarm  of  bees  from  a  hive,  and 
some  particles  of  which,  actively  revolving  as  they  went,  swam  off  to  the 
confines  of  the  field.  On  repeating  the  observation  and  allowing  some  aniline 
solution  to  flow  in  with  the  water  after  the  first  few  moments,  the  nuclei  were 
strongly  stained  and  beautifully  distinct,  although  the  movements  of  the 
molecules  promptly  ceased, — in  this  respect,  as  in  all  the  others,  showing  a  pre- 
cise identity  with  the  reactions  alforded  by  the  pus  and  the  salivary  corpuscles, 
as  above  described.  It  should  be  noted  that  a  certain  variable  proportion  of 
the  white  cells  of  the  blood  thus  treated  exhibited  no  moving  molecules,  and 
apparently  consisted  solely  of  nucleus  and  cell-wall." 

Since  the  above  was  in  type,  this  doctrine  seems  to  have  been  corroborated 
by  further  experiments  of  Dr.  Richardson,  in  which  salivary  globules  were 
again  reduced  to  the  size  of  the  white  cells  of  the  blood,  and  their  amoeboid 
movements  restored,  under  the  influence  of  a  three-quarter  per  cent,  solution 
of  common  salt.  (  Vide  paper  on  the  Structure  of  the  White  Blood-Corpuscles, 
Transactions  of  American  Medical  Association,  1872.) 


278  ORAL  DISEASES  AND  SVBGERY. 

one  piece  being  blue,  as  found  in  the  shops ;  the  other  made  red  by 
subjecting  it  to  the  action  of  a  weak  acid,  or  for  this  latter  purpose 
turmeric  paper  may  be  used.  Having  these  pieces  of  test-paper,  the 
patient  is  to  wet  them,  slip  after  slip,  at  varying  periods  of  the 
twenty-four  hours,  particularly  in  the  morning  immediately  upon 
rising  and  before  taking  anything  into  the  mouth.  If  persistently 
the  result  is  acid  or  alkaline,  as  evidenced  by  the  blue  slijjs  being- 
turned  red  if  the  first  condition  exists,  or  the  red  slips  of  litmus 
being  changed  to  blue,  or  the  yellow  of  the  turmeric  to  brown,  if 
the  action  is  alkaline,  then  is  primarily  indicated  the  necessity  for 
antagonizing  agents  as  suggested  in  the  prescriptions  presented  a 
few  pages  back. 

When  sordes  are  found  enveloping  the  teeth,  or  where  the  mucus 
is  glairy,  the  condition  manifested  by  such  secretions  is  to  find  cor- 
rection before  any  reasonable  hope  is  to  be  indulged  of  saving  the 
denture  or  of  making  mechanical  operations  which  may  have  in  them 
any  special  import  of  good.   (See  Mucoid  Saliva.) 

The  restoration  to  a  state  of  health  of  gums,  turgid  and  congested 
from  any  cause,  is  to  precede  dental  operations;  of  such  causes  of 
ulitic  troubles  there  are  many.  These  will  be  found  discussed  in  the 
chapter  on  Diseases  of  tlie  Gums.  In  a  word,  attention  to  local  or 
systemic  indications  is  to  precede,  or  have  association  with,  as 
judgment  may  determine,  the  operative  requirements  of  existing 
cavities  of  decay. 

2.  The  physical  history  of  a  tooth  to  be  treated  demands  con- 
sideration. Teeth  so  vary  in  character  as  to  suggest  their  division 
into  four  classes. 

I.  Teeth  of  the  Sanguine  and  Allied  Temperaments  with  Similar 
Hereditary  Association. — These  teeth  are  white,  shading  into  a  cream 
tinge  which  deepens  as  it  approaches  the  gum  and  as  age  advances: 
the  organs  are  uniform  in  dimensions  and  arrangement,  are  dense, 
and  have  periostea  of  the  most  resisting  character, — the  associated 
alveolar  process  being  condensed  to  a  corticle-like  extent ;  their  rela- 
tion with  the  jaw  is  so  unyielding  as  not  unfrequently  to  suggest 
union  of  the  parts.  Tliese  teeth,  as  justly  remarked  by  Harris,  indi- 
cate, "  if  not  perfect  health,  at  least  a  state  which  bordered  very 
closely  on  it  at  the  time  of  their  dentin! fication,  and  the  posses- 
sion of  stomachs  always  willing  to  digest  whatever  the  teeth  are 
ready  to  masticate." 

II.  Teeth  having  a  Blue  Shade. — These,  without  doubt,  are  much 
more  common  to  females  than  to  males.     Constitutionally  they  indi- 


LOCAL    TREATMENT  OF  DENTAL    CARIES.       279 

cate  the  lyrapliatic  temperament.  They  are  commonly  super-sensitive, 
Laving  a  softness  yet  tenacity  of  structure  that  expresses  dispropor- 
tionate excess  in  animal  matter  ;  observation  seems  to  indorse  the 
conviction  that  such  teeth  are  associated  more  or  less  in  a  hereditary 
history  with  struma.  Certain  it  is,  that  to  preserve  them  the  most 
constant  watchfulness  is  necessary,  both  as  a  systemic  and  a  local 
aspect  are  concerned. 

III.  Chalky  Teeth. — Teeth  of  this  class  are  not  unfrequently  to 
be  met  with  having-  so  little  mechanical  resistance  as  to  suggest 
their  relation  with  plaster  of  Paris.  As  such  teeth  have  in  them- 
selves no  resistive  force,  an  only  hope  of  prolonging  their  existence 
lies  in  the  antagonizing  of  agents  injurious  to  them.  Thus  arises  a 
necessity  of  that  care  on  the  part  of  a  person  so  afflicted,  which  is  to 
keep  him  informed  continuously  of  the  state  of  the  oral  fluids,  or  if 
such  care  is  not  consistent  with  the  character  of  the  individual, 
then  are  antacid  agents  to  be  kept  in  constant  use. 

lY.  Pearly  Teeth — Teeth  frequently  found  allied  with  the  Tuber- 
culous Predi.'iposifion. — Teeth  of  this  class  are  commonly  of  great 
symmetry,  being  in  harmony  with  the  delicate  stature  of  the  indi- 
vidual, and  akin  with  the  organization  which  has  produced  them.  The 
inherent  force  of  such  organs  is  much  in  proportion  with,  that  of  the 
common  body.  A  treatment  which  tends  to  preserve  them  is  that 
which  increases  the  physical  integrity  of  the  individual  at  large,  I 
am  not  aware  of  any  peculiar  local  tendency  to  disease  in  them.  The 
fluids  of  such  mouths  are  commonly  neutral. 

Teeth  of  the  first  and  fourth  classes  seldom  have  indications  of 
any  required  direct  preparatory  treatment.  Teeth  of  the  third  class 
may  only  have  immediate  adverse  associations  antagonized.  Teeth 
of  the  second  class,  however, — and  these  con.stitute  four-fifths  of  all 
diseased  teeth, — are  benefited  by  direct  local  medication  to  a  degree 
that  is  oftentimes  found  to  be  their  salvation. 

A  soft  moist  denture  indicates  non-resistance  on  the  part  of  the 
immediate  vital  force  (residing  in  the  organ)  to  the  advancing  dis- 
ease. There  is  here  little  or  no  antagonizing  structural  consolidation. 
Can  this  be  remedied  ?  Without  doubt,  in  perhaps  the  majority  of 
cases  it  can  ;  such  remedy  residing  in  stimulation  of  the  dental 
pulp,  and  in  affording  to  it  a  power  of  response.  To  secure  such 
response  implies  combination  Avith  the  local  of  general  stimulation. 
As  the  first  is  concerned,  it'Taas  been  implied  that  no  agent  sur- 
passes the  aqueous  solution  of  chloride  of  zinc  as  used  combined 
with    osteo-dentine.      A   soft,  non-resisting   tooth,   in   which   such 


280  ORAL  DISEASES  AND  SURGERY. 

a  temporary  plug  has  been  used,  will  not  unfrequently  in  the  course 
of  a  few  months  be  found  so  hard  that  an  ordinary  excavator  shall 
scarcely  be  able  to  make  an  impression  on  the  dentine ;  indeed,  in 
many  cases,  so  thorough  has  been  the  calcification  that  no  other 
treatment  is  found  necessary :  the  caries  has  been  cured,  the  dentine 
vitrified.* 

In  the  employment,  however,  of  such  stimulation,  it  is  to  be  in- 
ferred that  the  nicest  exercise  of  judgment  is  demanded.  Quite  as 
many  teeth  are  destroyed  by  chloride  of  zinc  fillings  as  are  saved ; 
perhaps  the  preponderance  is  to  the  first  side  ;  but  this  is  the  fault  of 
a  practice  which  overstimulates,  provoking  inflammation  and  sup- 
puration where  gentle  excitation  to  a  hypernutrition  is  alone  de- 
manded. A  good  rule  to  adopt  is  to  feel  one's  way,  recognizing 
always  that  the  extent  of  local  stimulation  is  to  be  commensurate 
with  the  ability  of  the  pulp  to  respond  ;  the  object  aimed  at  being  to 
re-excite  the  formative  capacity  of  the  pulp,  thus  to  oppose  advancing 
disease  by  securing  a  calciferous  barrier. 

Secondary  indications  to  be  met  preparatory  to  filling  a  carious 
tooth  exist  in  a  necessity  for  the  destruction  of  any  fungi  that  may 
be  found  in  the  cavity,  the  immediate  antagonism  of  the  carbonic  or 
other  acids,  or  any  alkali  temporarily  present,  and  the  saturation  of 
the  part  with  an  antiseptic, — warm  alcohol  being  about  the  best 
preparation  that  may  be  used  for  the  last  purpose.  By  saturation 
is  meant  that  the  dentine  be  bathed  in  this  fluid  after  the  preparation 
of  the  part  and  immediately  before  the  introduction  of  the  filling. 
A  person  undergoing  the  process  of  having  teeth  filled  should  freely 
use  as  a  rinse  alcohol  and  water,  combined  in  the  proportion  of  one 
part  of  the  first  to  four  of  the  second.  Or,  where  the  refrigerating 
influences  of  the  spirit  are  found  irritating  to  the  cavity,  it  may  be 
replaced  by  the  permanganate  of  potassa,  one  grain  to  the  ounce  of 
water.  Creaaote  is  also  justly  lauded  as  an  application  to  be  made 
to  the  walls  of  a  cavity  just  before  the  introduction  of  the  filling. 
Or  if  the  odor  of  this  medicament  is  objectionable,  it  may  be  replaced 
with  the  glycerole  of  thymol,  a  preparation  deemed  to  be  possessed 
of  all  the  virtues  of  the  former  article. 

*  Vitrifaction,  vitrified.  The  use  of  a  terra  signifying  glass — glass-like — 
would  in  such  a  case  seem  quite  as  permissible  as  its  application  to  one  of  the 
humors  of  the  eye,  the  condition  being  one  of  glass-like  hardness  and  smooth- 
ness. Eburnification,  or  conversion  into  a  substance  resembling  ivory,  is 
another  term  used  to  express  the  same  condition. 


CHAPTER   XII. 

THE   LOCAL   TREATMENT   OP   DENTAL   CARIES. 
FILLING  TEETH. 

The  treatment  of  carious  teeth  by  filling  presents  itself  under  the 
twofold  aspect  of  simple  and  complicated  cases.  The  first  considers 
cavities,  without  any  organic  expression  on  the  part  of  the  teeth 
affected.  The  second  associates  with  the  cavity  vital  complaint  of 
various  meaning.  In  other  words,  cavities  which  are  as  holes  in 
pieces  of  ivory,  the  filling  of  which  is  a  simple  mechanical  manipula- 
tion, to  be  done  well  or  ill,  according  to  the  skill  of  the  operator, 
and  cavities  which  demand,  previous  to  their  filling,  a  treatment 
fitting  them  to  endure  the  manipulation. 

Teeth  are  filled  or  stopped  with  various  materials,  the  principal 
agents  employed  being  gold,  tin,  amalgam,  chloride  of  zinc.  Hill's 
stopping,  and  gutta-percha.  The  basal  requirements  for  a  filling 
are — ability  to  withstand  the  mechanical  influences  of  mastication  ; 
resistance  to  chemical  agents ;  non-susceptibility  to  thermal  changes  ; 
qualities  to  admit  of  ease  of  introduction  into  a  cavity,  and  consoli- 
dation ;  harmony  in  color  ;  and  the  absence  of  properties  injurious  to 
the  structure  of  the  tooth  itself,  or  to  the  system  at  large. 

Of  such  different  materials,  the  very  best,  as  a  permanent  filling, 
is  gold  ;  after  this,  tin ;  the  other  agents  mentioned  being  employed 
chiefly  for  temporary  purposes,  —  for  example,  in  the  practice  of 
army  or  navy  surgeons,  or  by  physicians  whose  inclination  or  duties 
do  not  afford  that  practice  necessary  to  the  attainment  of  the  required 
skill  in  the  use  of  gold  or  tin.  The  plastic  fillings,  as  they  are  called, 
are  so  simple  and  easy  of  introduction,  that  any  trouble  in  their  use  is 
found  to  reside  almost  exclusively  in  the  preparation  of  the  cavity. 
(See  Directions.) 

Gold,  the  best  material  to  be  employed,  is  used  in  two  different 
forms, — gold-foil,  or  leaf  gold,  and  sponge  gold. 

Gold-foil  comes  to  the  operator  in  leaf  form,  done  up  in  books, 
these  leaves  being  of  varying  weight  from  two  to  two  hundred 

(281) 


282  ORAL  DISEASES  AND   SUBGERY. 

and  forty  grains,  the  number  on  the  book  designating  the  weight 
of  the  leaf.  Of  these  different  numbers,  some  operators  prefer  one, 
some  another:  it  is  perhaps  a  matter  of  choice  rather  than  of  real 
difference.  Leaf  foil  differs  also  in  the  characteristics  of  adhesive- 
ness and  non-adhesiveness.  The  first  is,  or  may  be  made,  so  sticky 
that  it  can  readily  enough  be  stuck  piece  to  piece,  or  welded.  In 
this  form  it  is  now  most  commonly  used,  and  maybe  quite  as  easily 
attached  and  built  upon  the  plane  surface  of  a  metal  dollar  as  within 
the  cavity  of  a  tooth.  To  effect  such  a  result,  it  is  only  necessary 
to  keep  the  part  and  metal  perfectly  dry,  and  to  use,  preferably, 
instruments  with  serrated  points  or  faces.  A  fault,  however,  fre- 
quently attaching  to  the  adhesive  gold,  and  which  may  result  from 
lack  of  care  or  skill  in  working  it,  lies  in  a  want  of  softness  or 
ductility. 

Unadhesive  foil,  employed  entirely  by  some  operators,  is  worked 
with  plain  pointed  instruments.  It  is  used  rolled  up  in  the  form  of 
cylinders  and  mats ;  as  pellets  ;  twists  ;  or  in  ribbon  strips :  however 
worked,  the  principle  of  manipulation  is  the  same,  being  that  of 
wedging,  one  piece  being  supported  by  another. 

Sponge  Gold. — This  preparation,  as  implied  in  its  name,  comes 
in  the  form  of  a  sponge  or  porous  mass.  It  is  most  adhesive,  and, 
as  with  the  sticky  foil,  if  kept  perfectly  dry  during  the  process  of 
manipulation,  can  be  attached  particle  to  particle,  until  a  tooth, 
however  broken  and  imperfect,  can  have  its  outlines  perfectly 
restored.  To  use  it,  serrated  pluggers  are  desirable,  and  the  por- 
tion of  the  mass  to  be  employed  is  to  be  separated  or  picked  into 
small  pieces  by  the  employment  of  instruments  rather  than  the 
moist  fingers.  A  large  piece,  or  a  bulk  of  size  sufficient  to  retain  its 
place  in  a  cavity,  is  to  be  first  introduced  and  worked  into  a  solid 
mass ;  to  this  first  piece  particle  after  particle  is  to  be  attached  until 
the  cavity  is  filled.  It  is  a  preparation  more  tedious  to  work  than 
the  foil,  and,  for  a  perfect  operation,  would  appear  to  demand  much 
more  skill,  and  infinitely  more  patience.  In  this,  however,  experi- 
ence seems  to  differ. 

Gold,  as  a  preparation  for  filling  teeth,  while  the  most  perfect 
article  employed,  is  yet  not  without  objections.  It  is,  unhappily 
for  this  purpose,  an  admirable  conductor  of  thermal  changes,  and 
when  used  in  close  proximity  with  the  pulp  of  a  tooth,  not  unfre- 
quently  so  irritates  this  organ  as  to  result  in  its  inflammation  and 
death.     Another  objection  lies  in  its  color. 

Tin-Foil.  —  This  is  simply  purified  tin  beaten  into  thin  leaves. 


LOCAL   TREATMENT  OF  DENTAL   CARIES.        283 

It  is  worked  precisely  as  gold-foil,  and  answers,  to  an  extent,  the 
same  purpose.  It  is  a  softer  metal,  and  less  capable  therefore  of 
resisting  the  wear  and  tear  of  mastication.  It  is  still  more  objec- 
tionable in  color  than  gold,  but  possesses  an  advantage  over  it  in 
being  a  less  sensitive  thermal  medium.  It  is  also  comparatively 
inexpensive.     Like  the  gold-foil,  it  is  furnished  in  books. 

Oxychloride  of  Zinc,  Osteoplastic,  Tooth-Bone. — This  is  a  prep- 
aration of  oxide  of  zinc,  silex,  titanium,  and  borax,  and  is  in  the 
market  in  the  form  of  a  whitish,  coarse  powder.  To  use  it,  a  small 
quantity  of  the  material  is  mixed  with  a  watery  solution  of  the 
chloride  of  zinc, — which  comes  already  prepared  with  the  powder ; 
and  in  the  form  of  a  paste,  thus  produced,  it  is  packed  into  the 
cavity.  The  most  perfect  dryness  is  necessary  to  any  success  in  its 
use ;  and,  if  possible,  the  filling  is  to  be  protected  from  the  fluids  of 
the  mouth  for  a  period  of  several  hours.  This  is  to  be  accomplished, 
— first,  by  shielding  the  mass  placed  in  the  tooth  while  in  the  act 
of  setting  or  hardening,  through  the  careful  employment  of  napkins 
and  bibulous'  paper ;  and,  second,  by  dissolving  in  chloroform  a 
sufficient  quantity  of  gutta-percha  to  make  a  thin  paste.  This, 
dropped  from  the  point  of  an  instrument  over  the  filling,  will  per- 
fectly coat  it,  and  remain  adherent  for  a  long  while, — quite  as  long 
as  is  necessary.  A  solution  of  gum  sandarac  may  be  used  for  the 
same  purpose. 

For  use  in  very  frail  front  teeth,  this  plastic  preparation  warmly 
commends  itself.  That  it  will  be  most  apt  to  need  frequent  renewal 
is  to  be  expected,  but  it  is  not  unfrequently  the  case  that  by  its  use 
they  may  be  saved  for  several  years,  while  in  such  teeth  it  has  an 
advantage  certainly  over  gold  in  the  matter  of  color.  Osteoplastic 
has  also  its  use  as  a  filling  for  the  pulp-chamber  and  as  a  non- 
conductor underlying  plugs  of  metal.  It  is  to  be  repeated  that  the 
highest  essential  to  its  integrity  consists  in  keeping  the  material 
perfectly  dry  for  as  long  a  period  as  possible  after  its  introduction 
into  a  tooth.  That  plugs  of  this  material,  when  in  relation  with  the 
necks  of  the  teeth,  are  found  to  fail  so  repeatedly  implies  oftentimes 
a  careless  manipulation,  which  has  allowed  the  filling  to  get  moist 
before  setting. 

A  form  of  artificial  dentine,  known  as  Guillois'  cement,  attracting 
at  present  a  good  deal  of  attention,  is  a  preparation  which  in  1856 
was  introduced  into  the  commercial  market  in  the  way  of  imitation 
coral, — sleeve-buttons,  shirt-studs,  and  similar  articles  being  made 
of  it. 


284  ORAL  DISEASES  AND   SUBGERY. 

Dental  societies  and  individuals  discussing  this  agent  disagree 
much  as  to  its  merits.  It  is  generally  conceded,  however,  that  as 
a  material  to  underlie  gold  it  is  not  surpassed,  while  many  of  much 
experience  insist  on  recommending  it  as  the  most  reliable  of  all  the 
plastic  materials.  It  is  manipulated  precisely  as  the  ordinary  oxy- 
chloride  of  zinc.  Dr.  Du  Bouchet,  of  Paris,  who  is  very  enthusiastic 
in  his  admiration  of  this  cement,  and  who  claims  most  satisfactory 
results,  thus  describes  his  manner  of  using  it: 

"  After  the  cavity  is  prepared  by  thorough  excavation,  though  it 
is  not  necessary  to  shape  as  carefully  as  for  gold  fillings,  place  a 
little  more  of  the  powder  upon  a  glass  slab  than  is  absolutely  neces- 
sary, and  near  it  a  drop  of  the  liquid  ;  then  mix  into  as  stiff  a  paste 
as  possible  by  means  of  a  small  platina  spatula,  and  with  which 
place  a  small  quantity  in  the  cavity,  pressing  it  into  all  parts  with 
a  small  inverted  cone-drill ;  then  fill  the  rest  of  the  cavity  with 
care,  and  allow  a  small  surplus  to  bulge  out,  overlapping  the  edges 
of  the  cavity:  then  dry  the  Qlling  with  bibulous  paper,  varnish, 
and  leave  for  another  sitting,  at  which  time  trim  with  chisel, 
and  polish  somewhat,  by  means  of  tape,  and  then  buckskin  ;  or, 
before  the  filling  has  entirely  hardened,  pass  a  burnisher  over  the 
surface  lightly  a  number  of  times,  taking  care  not  to  disturb  the 
setting;  this  makes  the  surface  quite  dense,  and  leaves  it  in  a 
better  condition  to  resist  the  saliva;  then  varnish.  By  means 
of  these  precautions  the  material  has  a  chance  of  becoming  ex- 
tremely hard  before  the  coat  of  varnish  has  worn  away,  leaving  it 
exposed  to  the  fluids  of  the  mouth, — its  only  enemies  in  these 
cases." 

An  objection  certainly  lying  to  the  use  of  this  cement  is  the  length 
of  time  required  in  setting,  thirty  minutes  scarcely  sufficing  for  that 
condition  which  justifies  the  removal  of  the  napkin.  The  ordinary 
American  compounds  set  in  from  two  to  five  minutes. 

Amalgam. — This  is  a  preparation  of  silver  and  tin  amalgamated 
with  mercury.  It  is  made  by  melting  together  varying  proportions 
of  the  two  first-named  metals,  say  equal  parts,  or  two  parts  of  silver 
to  three  of  the  tin — different  persons  having  different  formula} — and, 
when  thus  united,  is  comminuted  by  the  file,  and  put  aside  for  use 
when  needed.  This  material  is  furnished  by  the  depots  ready  for 
use,  being  on  sale  in  ounce  and  half-ounce  packages. 

To  make  an  amalgam,  or  paste  filling,  as  it  is  frequently  called, 
take  a  portion  of  these  filings,  enough  to  correspond  with  the  size 


LOCAL    TREATMENT  OF  DENTAL    CARIES.        285 

of  the  cavity  to  be  filled,  place  them  in  some  convenient  vessel,  add 
a  small  quantity  of  mercury,  rub  the  mass  together  for  a  few 
moments,  and  the  solid  grains  will  be  found  to  have  disappeared. 
Add  now  to  the  amalgam  a  few  drops  of  deliquesced  chloride  of 
zinc,  and  again  rub  the  whole  together.  As  a  result,  the  bottom  of 
the  vessel  will  be  covered  with  a  dirty,  black,  pasty  mass,  while  the 
amalgam,  robbed  of  its  impurities,  will  present  itself  as  a  fluid  ball 
of  frost-white  silver.  The  next  step  is  to  take  this  ball,  and,  envelop- 
ing it  in  buckskin,  cotton  cloth,  or  linen  stuff,  press  out,  with  for- 
ceps, the  excess  of  mercury;  the  result  is  now  a  semi-solid  mass, 
which  is  the  preparation  to  be  used  in  the  cavity  of  the  tooth.  To 
introduce  this  material,  it  is  only  necessary  to  thoroughly  dry  the 
cavity  with  bibulous  paper  or  other  absorbing  material — supposing 
the  cavity  to  have  been  previously  prepared — and  with  any  con- 
venient instrument  press  the  paste  into  place,  finishing  it  to  accord 
with  the  articulating  tooth.  A  few  hours,  and  it  will  be  found  to  have 
become  as  hard  as  the  tooth.  It  may  now  be  dressed  and  polished, 
and  the  operation  is  thus  completed. 

The  employment  of  the  chloride  of  zinc  as  a  purifying  agent  is 
not  at  all  a  necessity  in  the  preparation  of  the  mass,  and  may  be 
omitted  if  not  conveniently  at  hand.  This  mode  of  cleansing  amal- 
gam was  introduced  several  years  back  by  the  author,  and  seems  to 
have  passed  into  quite  common  use.  After  \Yashing  away  the  black 
sediment,  the  mass  is  to  be  thoroughly  dried  with  the  bibulous  or 
other  moisture-absorbing  paper;  such  drying  is  to  be  insisted  on,  as 
it  conduces  much  to  the  tenacity  of  the  mass,  through  an  influence 
on  the  process  of  crystallization. 

None  of  the  materials  employed  in  the  operation  of  filling  teeth 
has  elicited  so  much  discussion,  pro  and  con,  as  amalgam.  Without 
doubt,  it  will  turn  more  or  less  dark  every  tooth  into  which  it  is 
introduced,  and  on  this  single  account  is  not  to  be  used  in  the  front 
teeth.  Still  again,  it  oxidizes,  thus  giving  a  black  and  repulsive 
appearance  to  the  mouth  in  which  it  is  placed.  That  it  affects 
the  general  health,  as  affirmed  by  many  of  its  opposers,  is  not  per- 
haps to  be  accepted  as  true.  I  am  not  myself  able  to  recall  any 
decided  case  of  such  a  result.  That,  however,  used  in  conjunction 
with  other  metals,  the  influence  is  locally  bad,  can  scarcely  be 
denied, — although  exceptional  cases  may  exist.  No  material  is  in 
more  common  use  than  amalgam  ;  thousands  of  teeth  are  filled  with 
it  every  day,  and  it  is  not  to  be  denied  that  cases  enough  present 


286  ORAL  DISEASES  AND   SURGERY. 

where  such  a  filling  seems  the  only  one  that  can  be  used.  It  is 
claimed  that  if  a  tooth  be  properly  prepared,  and  the  material  be 
carefully  introduced,  an  amalgam  filling  will  last  quite  as  long  as 
would  one  of  gold.  Such  an  assertion  applies  only,  however,  where 
the  process  of  structural  consolidation  is  excited  by  the  presence 
of  the  plug,  or  where  the  dentine  of  a  tooth  is  naturally  very 
solid. 

The  use  of  amalgam  seems  necessitated  in  many  cases  in  which 
gold  cannot  be  used  and  w^here  tooth-bone  or  the  gutta-percha 
preparations  might  not  bear  the  demands  of  the  act  of  mastication 
or  the  action  of  chemical  antagonists.  In  the  teeth  of  soldiers, 
where  the  convenience  of  the  service,  lack  of  manipulative  skill  on 
the  part  of  the  surgeon  with  gold  or  tin,  or  the  habits  of  most  of 
the  patients,  would  render  the  use  of  gold  scarcely  permissible, 
amalgam  would  certainly  seem  to  recommend  itself.  (See  strictures 
of  Mr.  Bridgman,  on  the  electro-chemical  relations  of  the  amal- 
gams.) 

EilVs  Stopping. — This  is  a  preparation  composed  of  gutta-percha, 
quicklime,  and  feldspar  ;  it  is  to  bo  purchased  at  any  of  the  dental 
depots  at  a  very  reasonable  price,  and,  as  a  temporary  filling,  may 
be  highh'  commended:  such  a  plug  will  not  unfrequently  be  found 
preserving  a  tooth  for  several  months,  or,  it  may  be,  years.  To 
introduce  it,  it  is  only  necessary  to  soften  a  piece  of  the  size  required 
by  laying  it  upon  a  heated  plate,  and  while  in  such  plastic  condition 
introduce  it,  by  means  of  any  convenient  instrument,  into  the  pre- 
pared cavity.  Care  is  to  be  exercised  that  no  shreds  be  allowed  to 
override  the  orifice  of  the  cavity,  such  excess  being  easily  removed 
with  an  instrument  which  has  been  held  for  a  single  moment  in  the 
flame  of  a  spirit-lamp,  or  otherwise  it  may  be  dissolved  and  washed 
away  with  a  pellet  of  cotton  which  has  been  saturated  with  chloro- 
form. This  agent,  while  nicely  smoothing  the  filling,  is  thought, 
however,  by  many  to  render  it  porous  and  brittle.  The  only  objec- 
tion that  may  be  urged  against  this  compound,  if  used  in  accord- 
ance with  the  indications  of  cases  as  referred  to  in  the  previous 
chapter,  is  its  lack  of  durability. 

Gutta-Percha. — This  agent  is  not  unfrequently  employed  as  a 
temporary  filling  with  most  satisfactory  results.  It  is  treated  pre- 
cisely as  the  Hill's  stopping,  and,  as  is  seen,  resembles  this  stopping 
when  incorporated  with  other  materials.  "Where  one  desires  for 
himself  to  make  a  compound  gutta-percha,  it  may  be  done  by  mixing 


LOCAL    TREATMENT   OF  DENTAL    CARIES.        287 

a  powder  composed  of  quicklime  two  parts,  very  finely  pulverized 
quartz,  and  feldspar,  each  one  part;  the  softened  gutta-percha  is 
worked  with  this  powder  until  it  will  hold  no  more  without  be- 
coming brittle.  White  gutta-percha  is  in  itself,  however,  a  most 
admirable  temporary  filling  ;  it  adheres  tenaciously  to  the  walls  of 
a  perfectly  dry  cavity,  and  where  it  has  been  inserted  with  proper 
care  may  be  depended  on  to  preserve  a  tooth  for  a  long  time.  I 
have  seen  a  tooth  and  plug  as  good  after  two  years'  service  as  on  the 
day  of  the  operation.  A  filling  of  gutta-percha  will  commend  itself 
above  all  others  in  very  many  instances.  I  have  certainly  seen  it 
preserve  teeth  where  the  cavities  were  situated  on  the  buccal  and 
proximal  faces  of  the  molars  and  bicuspidati,  in  cases  where  gold 
had  failed,  an  explanation  of  which  would  seem  to  be  found  in  the 
illustration  as  exhibited  in  Mr.  Bridgman's  experiments. 

A  form  of  gutta-percha  preferred  by  many  is  that  employed  for 
making  test-plates.  Some  of  this  is  found  exceedingly  tough  and 
resistive,  and  will,  without  doubt,  make  a  filling  which  may  be 
trusted  for  a  long  time. 

From  this  review  of  the  materials  employed  in  filling  teeth  we 
may  pass  to  instruments  and  apparatus  required  in  the  manipula- 
tions. 

Excavators. — An  excavator  is  an  instrument  designed  to  excavate 
or  clean  out  a  cavity.  Excavators,  while  variously  modified,  are 
founded  on  two  elementary  styles  :  one,  hoe-like  in  shape,  cutting 
as  drawn  toward  the  operator,  the  other  represented  by  the  relation 
of  the  edge  of  the  ordinary  hatchet  to  its  shaft  or  handle. 


Fig.  62. — Hoe  Excavators  and  Modifications. 

1  n  n  n  n  n  r 


288  OBAL  DISEASES  AND  SURGERY. 

Hoe  Excavators  and  MoDiFiCATroNS. 


Pig.  63. — Hatchet  Excavators  anb  Modifications. 


II     I   »   '" 


OOft  fl 


Fig.  64. — Rose  Drills  and  Spear  Drills. 


1 1 


LOCAL    TREATMENT  OF  DENTAL    CARIES.        289 
KosE  Drills  and  Speak  Drills. 


V     w 


Examination  of  the  diagrams  gives  tbe  general  idea  of  these  in- 
struments. Unless,  however,  made  of  the  finest  steel,  and  shaped 
and  tempered  with  the  nicest  appreciation  and  care,  it  is  impossible 
to  execute  with  them  the  requirements  demanded.  Excavators  fit 
for  the  hand  of  the  operator  should  first  be  able  to  endure  the  test 
of  an  unturned  edge  when  used  to  cut  a  cavity  in  a  piece  of  ivory. 

Drills — Rose  and  Spear. — Associated  for  a  common  purpose  with 
the  excavator  are  the  spear  and  rose  drills  ;  these  instruments,  per- 
fectly exhibited  by  the  diagram,  are  found  happily  adapted  to  the 
reaming  out  of  cavities  upon  tiie  grinding  and  other  exposed  sur- 
faces of  the  teeth.  When  properly  tempered,  they  cut  with  great 
rapidity,  and  while  clearing  the  cavity  tend  also  to  give  convenient 
shape  for  the  retention  of  the  filling.  They  are  used  also  for  the 
purpose  of  securing  what  are  called  retaining  points  for  plugs,  a 
matter  to  have  consideration  in  connection  with  particular  cavities. 
Drills,  like  excavators,  are  made  with  handle  and  point  in  one  piece, 
or  are  fitted  to  separate  handles,  which  may  be  made  of  steel,  ebony, 

19 


290 


ORAL  DISEASES  AND  SURGERY. 


pearl,  or  more  expensive  material,  to  please  the  taste;  the  single 
piece  is.  however,  commonly  preferred,  as  being  the  most  con- 
venient form.  To  use  this  instrument  it  is  only  necessary  to  rotate 
it  between  the  thumb  and  finger,  or,  where  pressure  is  found  desir- 
able, the  palm  of  the  hand  may  be  spared  by  receiving  the  butt  of 
the  drill  in  a  socketed  ring  or  thimble.  Drills  are  also  used  associ- 
ated with  handles,  which  allow  of  application  at  any  angle  desired. 
Of  such  stocks  there  are  quite  a  variety,  the  most  simple  of  which 
is  perhaps  that  known  as  Merry's.     Fig.  65  exhibits  this  drill  as 


Fig.  65. 


Fig.  66. 


Merry's  drill,  ivory  handle. 


Bur  thimble. 


ready  for  use.  Fig.  66  represents  the  bur  thimble :  this  consists  of 
an  open  ring  for  the  middle  or  the  index  finger,  with  a  socket  at- 
tached, in  which  rests  the  end  of  the  handle  of  the  drill.  It  not 
only  saves  the  hand,  but  the  instrument  is  rotated  much  more  easily. 

Instruments  more  lately  introduced,  and  growing  rapidly  in 
favor  with  operators,  are  Green's  pneumatic  engine,  Morrison's 
burring  apparatus,  Black's  and  Bonwille's  office  lathe  and  finishing 
drill.  These  are  all  labor-saving  machines,  and  would  seem  pos- 
sessed of  that  principle  which  must  eventually  bring  them  into 
general  use.  While  these  various  appliances  have  a  common  pur- 
pose,— namely,  the  rotation  of  instruments  used  in  preparing  cavi- 
ties, cutting  down  and  finishing  fillings,  removing  tartar,  polishing 
teeth,  etc., — the  first  differs  from  the  others  in  having  its  power 
supplied  by  a  bellows  which  is  conveniently  worked  by  the  foot, — 
Morrison's,  Black's,  and  Bonwille's  being  worked  by  a  treadle 
applied  as  in  the  ordinary  lathe. 

It  is  claimed  by  the  devisers  of  these  various  instruments  that 
not  only  is  there  great  economy  of  time  through  their  use,  afford- 


LOCAL    TREATMENT  OF  DENTAL   CARIES.        291 

ing  to  an  operator  the  ability  to  fill  many  more  teeth  in  a  given 
period,  but  that  in  every  respect  greater  comfort  is  secured  to  the 
patient,  the  instruments  destroying,  through  rapidity  of  revolu- 
tion,— from  fifteen  hundred  to  four  thousand  in  a  minute, — the  sen- 
sibility of  dentine,  relieving  from  the  necessity  of  severe  extension 
of  the  lips  and  prolonged  sittings,  and  accomplishing  besides  a  char- 
acter of  work  that  could  not  otherwise  be  secured.  An  understanding 
of  these  instruments  is  had  by  referring  to  the  Merry  drill ;  the  new 
apparatus  represents  simply  the  application  of  power  to  this  form  of 
machine.  The  oral  surgeon  who  may  find  himself  closely  restricted 
to  the  operations  upon  the  teeth  must  certainly  discover  his  conveni- 
ence and  comfort  consulted  in  employing  in  his  practice  the  aid  of  such 
appliances.  An  objection  offered  against  their  use,  but  one  which 
the  manufacturers  will,  without  doubt,  shortly  overcome,  is  deficiency 
in  working  with  that  trueness  which  enables  the  operator  to  possess 


Fig.  67. — Forms  of  Chisels  used  in  Dentistry. 

/I 


292 


ORAL  DISEASES  AND  SURGERY. 


Fig.  68. — Jack's  Double-End  Enamel  Chisels. 


over  his  drill  the  desired,  and,  indeed,  absolutely  neces- 
sary, control. 

Instruments  most  frequently  found  demanded  for  such 
exposure  of  a  cavity  as  shall  allow  manipulation  with 
the  excavators  and  drills,  are  chisels  and  files.  All  cavi- 
ties in  proximal  surfaces  require  the  employment  of  these 
instruments.  Both,  as  would  be  inferred,  have  a  variety 
of  modifications.  But  with  whatever  particular  one  an 
operator  may  find  himself  able  most  conveniently  to  meet 
the  indications  of  his  case,  that  is  the  one  he  is  to  employ. 
As  experience  has  made  felt  the  necessity  for  the  modi- 
fications, so  a  very  little  practice  will  best  show  the 
operator  which  of  the  forms  he  may  select  to  meet  his 
purpose. 

Fig.  61  exhibits  the  style  and  form  of  chisels  in  or- 
dinary use.  A  modification  on  these  chisels  is  known  as 
Jack's  double-end  enamel  cutters.  Six  instruments- con- 
stitute a  set,  such  a  set  being  designed  to  furnish  "  all 
the  forms  needed  for  freely  cutting  the  enamel  in  sep- 
arating teeth."     Fig.  68  exhibits  these  chisels. 

Still  another  character  of  chisels  are  those  designed 
for  opening  fissures,  cutting   retaining  points,  and    also 


LOCAL    TREATMENT   OF  DENTAL    CARIES.  293 

Fig.  69. 


i 


1 


i 
■ 


for  enamel  cutting,  wherever  applicable.  Fig.  69  exhibits  what 
are  known  as  Forbes's  gouge  and  Jack's  paraboloid  chisels, — 
instruments  in  general  favor  with  operators,  and  capable  of  ac- 
complishing their  work  most  satisfactorily. 

Nos.  1,  2,  3,  t,  8,  and  9  show  the  Forbes's  gouge ;  and  Nos. 
4,  5,  6,  10,  11,  and  12  illustrate  Dr.  Jack's  paraboloid  chisels. 

Files. — Fig.  TO  represents  a  simple  straight  file,  which  is 
to  be  viewed  as  the  base  from  which  the  varieties  digress.  A 
file  of  such  form  would  at  once  be  accepted  as  well  adapted  to 
separating  two  proximating  surfaces,  as,  for  example,  the  in- 
cisor teeth. 

Such  plain  files,  while  alike  in  general  form,  differ  greatly  in 
thickness  of  blade  and  depth  of  cut,  some  indeed  being  so  deli- 
cate as  rather  to  act  the  part  of  burnishers,  following  those  of 
heavier  cut.  Plain  files  are  employed  in  separating  the  ante- 
rior ten  teeth,  superior  and  inferior. 

A  form  of  plain  file  preferred  by  many  operators  is  that 
suited  to  a  common  carrier.  Fig.  Tl  represents  such  a  file  and 
carrier. 

A  form  of  separating  file  in  common  use,  without  doubt  the 
most  convenient,  and  the  least  expensive,  is  exhibited  on  a  fol- 
lowing page.  (Fig.  79.)  These  are  to  be  procured  in  packages 
of  assorted  sizes. 

Separating  files,  so  modified  as  to  be  adapted  for  convenient 
use  with  the  back  teeth,  are  also  shown.    (Fig.  85.) 

Having  thus  exhibited  the  instruments  necessary  for  the  exposure 
and  preparation  of  a  cavity,  we  pass  to  the  study  of  the  manipula- 


294 


ORAL   DISEASES  AND  SURGERY. 


tions  ;  and  first  we  consider  the  most  simple  of  cavities,  i.e.  a  hole 
more  or  less  round,  situated  on  the  grinding  face  of  a  molar  tooth. 
In  Fig.  "72  are  exhibited  a  number  of  these  simple  cavities.  Sulci, 
so  presenting,  vary  in  the  extent  of  the  underlying  decay  as  influ- 
enced by  the  structure  of  the  organs  in  which  they  are  found.  In 
teeth  of  dense  material,  for  example,  they  will  seldom  be  found  larger 
within  than  at  the  orifice.  On  the  contrary,  where  the  dentine  is 
loose  and  non-resisting,  as  found  in  classes  two  and  three,  a  very 

Fig.  70. — Separating  File. 


small  orifice  will  not  unfrequently  be  found  to  lead  to  most  exten- 
sive disorganization.  To  prepare  such  cavities  for  filling,  an  operator 
may  use  either  excavator  or  drill,  as  may  be  preferred  :  perhaps  the 
most  simple  means  is  found  in  the  drill:  selecting  a  size  suited  to 


FiQ.  71. 


mmmmmmmm 


Fig.  72. 


the  orifice,  the  operation  consists  simply  in  reaming  out  the  hole, 
the  single  precaution  being  observed  of  having  the  common  diameter 
of  the  cavity  as  large  as  the  outlet;  to  have  it  a  trifle  larger  is 
better,  as  thus  a  filling  is  retained  with  greater  security. 

In  cases  where,  after  breaking  through  the  orifice,  a  large  cavity 
is  seen  to  exist,  drill  after  drill  of  increasing  sizes  may  be  employed, 

thus  making  the  circumference  of  the 
orifice  correspond  with  the  cavity 
being  made  within.  Or  in  such  cases 
as  present  a  resisting  enamel  the 
orifice  is  to  be  most  conveniently 
enlarged  through  the  use  of  the 
chisel.  Selecting  one  of  suitable  size, 
the  operator,  little  by  little,  chips 
away  the  operculum  until  the  circumference  of  the  diseased  dentine 
is  exposed  ;  this  accomplished,  it  remains  only  to  refer  to  the  drill 
or  excavator.  In  using  a  rose  drill,  the  precaution  is  to  be  taken  of 
avoiding  the  evolvement  of  discomforting  heat  ensuing  from  rapidity 
of  rotation,  which  is  to  be  done  by  careful  drilling,  or  otherwise  the  fre- 
quent dipping  of  the  instrument  in  cold  water. 


Simple  cavities  on  grinding  face 
of  molars. 


LOCAL    TREATMENT   OF  DENTAL    CARIES.        295 

Fig.  73  represents  cavities  frequently  found  on  the  posterior  face 
of  incisor  teeth.  Such  cavities  correspond  closely  in  their  mode  of 
preparation  with  those  just  described.  A  peculiarity  occasionally 
observed,  however,  exists  in  the  tendency  of  a  delicate  line  of 
disease  to  start  from  the  bottom  of  the  common  cavity,  making  its 
way  directly  toward  the  pulp-chamber:  where  such  line  is  found,  it 
is  neither  necessary  nor  desirable  to  associate  it  with  the  first 
cavity  otherwise  than  by  a  reaming  correspondent  with  its  own 
size :  should  it  be  found  to  increase 
greatly  in  sensibility  as  it  approaches 
the  pulp,  ray  own  experience  has  satis- 
fied me  that  it  is  much  the  best  plan  to 
allow  a  portion  of  the  diseased  dentine 
to    remain:    harm   will    not   be   apt   to    „    ...  .   ■    r       .■    ■ 

'  '^  Cavities  on  posterior  face  of  incisors. 

ensue  from  its  presence  if  it  be  disin- 
fected and  put  into  a  state  of  neutrality,  such  diseased  neutralized 
dentine  most  frequently  becoming  encysted ;  that  is  to  say,  when 
properly  treated, — as  has  been  referred  to, — being  surrounded  by 
a  wall  of  consolidated  tubules,  while  protected  of  course  externally  by 
the  overlying  filling.  Rose  drills  are  commonly  used,  to  the  ex- 
clusion of  other  instruments,  in  the  preparation  of  these  cavities, 
although  the  occasional  convenience  of  the  excavator  is  not  to  be 
denied.  Great  care  is  to  be  exercised  in  these  cases,  as,  indeed, 
in  all  others,  to  have  the  orifice  of  the  cavity  sharply  defined  in 
its  circumference ;  if  it  be  strictly  round,  so  much  the  better,  as 
thus  the  material  used  in  filling  can  be  made  the  more  easily  to  asso- 
ciate harmoniously  with  it :  such  union  being  an  absolute  essential 
to  the  integrity  of  any  plug. 

Fig.  74.  Ftg.  75.  Ftg.  76. 


Cavities  at  neck — anterior         Cavities  found  in  the  midst  Cavities  on  buccal  face  of 

face^of  incisors.  of  imperfect  enamel.  molars. 

Fig.  74  represents  what  may  be  described  as  the  third  class  of 
cavities :  they  are  very  frequently  met  with  in  the  position  shown  in 
the  cut.  A  more  common  location,  however,  is  on  the  buccal  face 
of  the  molar  teeth  in  a  sulcus  about  midway  of  this  face. 

When  situated  as  seen  in  the  drawing,  part  of  the  cavity  being 
overlaid  by  the  gum,  it  will  be  found  most  convenient  to  remove  a 


296  ORAL  DISEASES  AND  SURGERY. 

portion  of  the  carious  dentine  by  the  use  of  the  excavator,  and,  thus 
securing  a  cavity,  stuff  it  firmly  with  a  cotton  filling,  which  is  to  be 
allowed  to  project  to  some  little  extent ;  this  filling,  as  it  absorbs 
moisture  and  swells,  naturally  throws  the  gum  from  off  the  cavity, 
thus  allowing  the  completion  of  the  excavation  as  described  in  the 
previous  cases. 

Fig.  *75  represents  a  condition  of  imperfect  enamel,  in  which  are 
frequently  found  a  number  of  pits:  if  examination  reveals  the  bot- 
tom of  such  pits  to  be  enamel-covered,  they  need  not  be  filled  ;  if, 
however,  the  sharp  point  of  the  instrument  used  for  the  exploration 
be  found  to  stick  or  wedge,  then  the}^  are  to  be  reamed  out  with  the 
spear  or  rose  drill.  Not  to  treat  and  fill  such  cavities  would  be  to 
allow  caries  to  destroy  the  teeth.  Unless  of  themselves  running 
into  each  other,  these  cavities  are  not  to  be  associated.  Situated  on 
the  buccal  faces  of  the  molars,  such  cavities  are  to  be  reamed  out 
with  the  rose  drill.     A  complication  frequently  found  to"  exist  is 

where,   starting  from   such   a 
-^^°"  ' '•  point,  or  it  mny  be  in  an  abra- 

sion near  the  neck  of  the  tooth, 
the  disease  extends  laterally, 
scooping  out,  as  it  were,  a 
cavity  (Fig.  77)  :  here  the  ex- 
cavities  on  buccal  .ace  of  molar..  cavator  Is  fouud  most  Conve- 

nient, while  the  employment  of  the  chisel  to  uncover  the  caries  is 
most  likely  made  necessary.  In  excavating  cavities  of  this  aspect, 
it  is  common  to  have  a  slight  undercut  immediately  beneath  the 
enamel ;  such  undercut  being  necessary  for  the  support  of  the  filling. 

From  cavities  situated  as  just  described,  we  pass  to  the  consid- 
eration of  others  so  related  as  to  demand  for  their  exposure  not  only 
ingenuity,  but  also  such  clinical  data  as  shall  show  what  extent  of 
chiseling,  filing,  or  pressure  is  permissible,  not  alone  as  the  endurance 
of  the  teeth  is  concerned,  but  as  reference  shall  be  bad  to  appear- 
ance, and,  where  possible,  to  self-cleansing  surfaces. 

The  denture  shown  in  Fig.  78  is  a  type  of  many  often  exhibiting 
themselves.  Upon  the  left  side  are  shown  the  teeth  as  involved  by  the 
caries  when  a  patient  presents  himself.  Upon  the  opposite  side  are 
represented  the  same  cavities  when  made  ready  to  receive  the 
filling.  The  second  and  third  molars  of  left  side,  however,  are 
utilized  to  exhibit  contour  cavities. 

Proximal  cavities  are  to  be  exposed,  by  V-shaped  filing.     This  is 


LOCAL    TREATMENT  OF  DENTAL   CARIES.       297 


tbe  common  rule,  yet  having  exceptions,  as  will  hereafter  be  ex- 
plained. A  central  incisor  tooth,  decayed  upon  the  surface  con- 
cealed bv  its  neighbor,  the  relation  of  the  teeth  being  as  exhibited 


Fig.  78. 


Fig.  79. 


Carious  denture. 

in  the  diagram,  the  operation  of  exposure  is  commenced  by  passing 
a  delicate  separating  file  between  the  two 
teeth,  a  shoulder,  however,  being  left  at  the 
neck,  which  is  to  prevent  the  future  falling 
together  of  the  cut  faces.  Space  for  the  play 
of  the  file  being  thus  secured,  the  first  in- 
strument is  replaced  by  a  second,  this  latter 
being  curved  in  its  blade,  and  having  a  single 
cutting  surface,  which  is  slightly  convex. 

With  the  convex  file,  it  is  plainly  seen  that 
it  is  only  necessary  to  incline  the  free  face 
against  the  tooth  not  to  be  cut,  that  the 
inclined  plane  looking  inward  shall  be  made 
to  act  upon  the  affected  tooth.  (See  diagram.) 
When  the  decay  is  common  to  both  teeth, 
the  double  filing  is  seen  to  make  the  Y-cut 
with  the  base  backward.  Looking  at  the 
central  incisor  on  the  right  of  the  diagram, 

separating   tiles. — (llie  tiist  "  ... 

is  of  convex  face.)  the  cavitv  (shown  ou    the    left   incisor)  is 

found   placed  on  the  inclined  plane,  all   its 

parietes  being  exposed  and  easy  to  get  at.     This  has  been  the  result 


298  ORAL  DISEASES  AND  SURGERY. 

of  the  filing.  The  tooth,  while  widely  separated  from  its  fellow 
behind,  affording  plenty  of  room  for  operating,  shows  in  front  but  the 
space  made  by  the  passage  of  the  delicate  separating  file.  This  mode 
of  separating  applies  to  the  six  anterior  teeth. 

After  making  the  primary  cut  with  the  separating  file  between 
the  teeth  from  the  front,  it  is  the  habit  with  many  operators  to  rely 
for  the  back  separation  principally  on  the  chisel.  If  handled  deli- 
cately, there  is  perhaps  little  doubt  that  this  instrument  is  found 
least  disagreeable  to  the  patient,  and,  when  used  sharp  and  of  proper 
curvature,  it  will  most  satisfactorily  accomplish  the  work :  the  file, 
however,  is  commonly  employed  to  finish  the  separation. 

A  proximal  cavity,  without  complications,  thus  exposed  (see  cen- 
tral, lateral,  and  cuspid  teeth  in  diagram),  nothing  remains  but  to 
treat  it  as  the  simple  cavities  before  described, — that  is,  cut  away  the 
carious  dentine,  and  form  the  cavity  of  a  shape  to  retain  the  filling. 
Such  excavating  is  generally  done  with  the  hoe  and  hatchet  exca- 
vators, the  head  of  the  patient  being  thrown  backwards.  The  rose 
and  spear  drills,  however,  at  times  are  here  found  very  convenient  of 
use,  particularly  where,  the  cavity  being  of  saucer-shape,  what  are 
called  retaining  points  are  required. 

Complications. — The  cavities  just  described  are  those  of  such 

limited  size  as  to  have  made  no  alteration  in  the  front  or  back  faces 

of  the  teeth.     From   the  consideration  of 
Fig.  80.  ,  ,  ,  ^    ,   . 

such  we  pass  to  a  class  as  represented  m 

Fig.  80,  where,  as  is  seen,  the  labial  face 

is  markedly  affected. 

In  examining  these  teeth,  let  the  student 

draw  a  transverse  line  midway  between  the 

cavities  and  the  gum.  From  this  first  line 
let  him  drop  vertically  others  which  shall  just  include  the  carious 
breaks  on  the  faces  of  the  teeth.  Where  the  cavities  are  no  more 
extensive  than  exhibited  in  the  diagram,  he  will  find  that  the  file 
removing  all  between  his  lines  will  yield  no  deformity,  but  afford, 
on  the  contrary,  a  space  possessed  of  healthy  look  and  not  unbe- 
coming singularity.  As  a  next  step,  let  the  convex-faced  file  be 
used,  cutting  wider  the  space  posteriorly  so  as  to  allow  the  cavity 
to  be  seen  only  from  that  surface.  He  has  thus  his  cavities  in  the 
same  position  and  relation  as  existing  in  the  cases  above  described. 
A  second  complication  on  such  order  of  cavities  is  where  the 
teeth  affected  are  so  related  to  each  other  and  to  the  arch,  and 
the  cavities  of  so  extensive  a  character,  as  to  make  any  alteration  in 


LOCAL    TBEATMENT   OF  DENTAL   CARIES.        299 

the  outlook  impossible.  Cases  of  this  kind  are  found  where  caries 
has  extended  its  ravages  over  half  the  anterior  face  of  the  tooth,  or 
where  a  tooth  has  such  position  in  the  arch  that  what  should  be  the 
proximal  surface  is  found  looking  almost  directly  forward,  the  tooth 
being  twisted,  as  it  were.  Conditions  of  such  expression  are  com- 
monly treated  by  excavating  in  any  manner  found  most  convenient; 
the  original  contour  of  the  tooth  being  restored  by  the  filling;  other- 
wise such  teeth  may  be  filed  in  front  until  resisting  parietes  to  the 
cavities  are  found,  and  then  treated  precisely  as  in  the  case  of  the 
posterior  V.  Teeth  having  the  base  of  the  V  looking  forward  are 
of  course  objectionable,  but  many  so  treated — the  fillings  being  very 
solid  and  highly  fioished — are  far  from  unsightly. 

Another  class  of  complications  exist  in  teeth  related  as  in  Fig.  81. 
Taking  the  central  incisors  as  the  first 
demonstration  ;  the  tooth  on  the  right  Fig.  81. 

side  of  the  diagram  is  seen  to  over- 
ride its  fellow  and  to  impinge  alone 
near  the  cutting  edge.  In  cases  of 
this  kind  it  is  scarcely  probable  that 
either  file  or  chisel  will  be  found  admis- 
sible, as  it  is  plainly  seen  that  no  expedient  will  apply  to  prevent  the 
cut  surfaces  falling  again  together.  In  exposing  the  cavities  in 
these  cases, — if  found,  as  is  usual,  on  the  covered  surface, — the 
means  employed  is  that  of  pressure,  either  a  wedge  of  some  soft  wood 
or  a  section  of  tough  rubber  tubing  being  employed.  Of  the  two 
means,  the  immediate  wedging  by  the  wood  is  found  to  afford  the  least 
pain,  a  wedge  of  the  proper  size  being  driven  delicately  between  the 
teeth  until  sufficient  room  to  work  at  the  cavity  has  been  secured. 
Where  the  india-rubber  is  used,  it  is  common  to  exert  the  pressure 
gradually,  pieces  of  increasing  size  being  introduced  until  the  desired 
separation  is  obtained.  Objection  to  such  means  of  separating  teeth 
lies  in  the  soreness  provoked,  the  subsequent  operation  of  filling  being 
at  times  rendered  so  painful  as  to  be  nearly  if  not  quite  unbearable.  In 
using  the  wedge  of  wood,  the  separating,  excavating,  and  filling  are 
to  be  done  at  the  same  sitting.  To  introduce  such  a  wedge,  it  is  found 
most  convenient  to  cut  it  on  the  end  of  a  stick  of  some  length,  nick- 
ing deeply  at  the  base  of  the  wedge.  It  is  thus  easily  thrust  by  the 
hand  between  the  teeth,  or  allows  of  the  convenient  application  of 
the  required  force  by  the  mallet.  When  in  place,  the  wedge  is  cut 
off  at  the  nick. 

Referring  again  to  the  diagram.  Fig.  81,  another  modification  is 


300 


ORAL  DISEASES  AND   SURGERY. 


Fig.  82. 


found  in  the  relation  of  the  lateral  incisor  of  the  right  side  to  the 
central.  As  in  the  case  of  the  central  with  its  fellow,  it  is  seen  to 
override,  but  it  differs  from  this  first  in  possessing  an  impinging 
surface,  continuing  from  the  cutting  edge  to  the  neck.  Teeth  so 
related  are  to  be  separated,  first,  by  the  wedge  introduced  at  the 
neck ;  and,  second,  may  have  the  space  thus  secured  increased  by 
the  file,  the  cutting,  however,  to  be  so  directed  as  to  leave  at  the 
neck  an  unfiled  portion  which  shall  prevent  the  parts  falling  again 
together,  after  the  removal  of  the  wedge.  To  excavate  and  fill  a 
cavity  in  such  a  situation  would  seem  to  be  a  very  difficult  matter, 
and,  indeed,  will  be  found  so,  unless  the  operator  forces  for  himself 
space,  and  which  in  all  instances  is  to  be  effected,  wedges  of  wood 
or  india-rul)ber  and  the  file  being  used  as  found  necessary.  It  is  to 
be  accepted  as  a  rule  that  the  file  may  be  used  where  after-changes 
are  not  to  bring  the  cut  surfaces  in  contact. 

Still  another  modification  is  exhibited  in  Fig.  82.  Here  the  gums 
are  found  somewhat  receded,  the  necks  of  the  teeth  being  exposed. 
In  the  proximal  surface  of  each  tooth  near 
the  gums  is  a  cavity  of  decay.  To  get  at 
such  cavities,  the  space  made  by  nature  in 
the  V-spaces  seen  in  the  diagram  may  be  all- 
sufficient.  If  this  should  not  be  the  case, 
then  the  wedge  may  be  employed,  being 
driven  midway  between  the  cavity  of  decay 
and  the  cutting  edge.  Such  cavities  being  excavated  and  filled,  the 
teeth  are  allowed  to  fall  together.  It  must  be  seen  that  the  mis- 
fortune of  fillings  so  placed  would  lie  in  the  absence  of  self-cleansing 
properties,  compelling  thus  continual  care  for  their  preservation. 
To  obviate  such  an  objection,  the  use  of  the  chisel  has  been  advo- 
cated, scooping  out  a  Y-space  which  is  to  extend  from  the  neck  to 
the  cutting  edge,  treating  such  teeth,  indeed,  precisely  as  described 
with  the  uncomplicated  cases, — a  plan  undoubtedly  to  be  preferred 
where  no  lateral  pressure  exists  to  force 
the  cut  surfaces  together. 

In  Fig.  83,  representing  the  six  inferior 
anterior  teeth,  the  same  condition  is  ex- 
hibited as  shown  in  Fig.  82.  The  plan  of 
treatment  would,  of  course,  be  the  same. 

Other  modifications  connected  with  the 
anterior  teeth  will  not  unfrequently  be  en- 
countered, but  with  the  general  ideas  here  given  the  ingenious  operator 


Fig 


LOCAL    TREATMENT   OF  DENTAL    GAR  FES. 


301 


will  find  in  his  own  skill,  after  a  little  experience,  all  the  directions 
required. 

In  deciding  on  a  mode  of  separating  teeth,  the  practitioner  will 
find  constant  demand  for  the  exercise  of  judgment.  It  may  be  laid 
down,  however,  as  a  rule  that  never  more  than  two  teeth  should  be 
undergoing  the  process  in  the  same  mouth  at  the  same  time.  When 
the  rubber  is  used,  it  is  also  to  be  accepted  as  a  rule  that  plenty  of 
time  should  be  allowed  for  the  operation, — from  two  to  five  days 
being  about  the  time  required  ;  that  when  soreness  arises  no  increase 
in  the  thickness  of  the  rubber  is  to  be  made  until  it  has  subsided. 
As  a  rule,  young  teeth  endure  displacement  better  than  old  ones  ; 
indeed,  it  seems  to  be  a  conclusion  of  many,  that  separation  of  the 
teeth  in  persons  over  forty  years  of  age  may  be  made  with  safety 
alone  by  the  file. 

In  filling  proximal  cavities,  occasion  is  often  felt  for  the  use  of  a 
very  temporary  matrix, — a  form  of  instrument  lath-shaped  in  blade, 


Fig.  84. 


^ 


II 


which  may  be  passed  between  the  teeth,  making  a  wall  of  suppoi't 
for  the  gold  until  convenience  allows  of  its  condensation.  The  flat 
blade  No.  5  from  the  right,  Fig.  84,  represents  such  an  instru- 
ment. It  is  a  blade  which  will  be  felt  to  contribute  very  much  to 
facility  in  filling  such  cavities.  To  use  it,  it  is  simply  necessary  to 
rest  it  flatwise  against  the  neck-wall  of  the  cavity,  creating  thus  a 
fully-bounded  hole  into  which  the  gold  is  worked.  (See  3Iatrices.) 
Modifications  of  excavators  are  also  exhibited  in  Fig..  84,  which 
will  be  found  uiost  valuable  in  excavating  ;  indeed,  than  the  forms 
1,  2,  3,  5,  and  6,  left  side  of  diagram,  none  better  may  be  found. 


302  ORAL   DISEASES  AND   SURGERY. 

They  cannot  be  too  highly  commended,  being  recognized  to  apply  to 
almost  every  form  and  position  of  cavity. 

Passing  now  to  the  bicuspid  teeth,  the  diagram  Fig.  78  ex- 
hibits approximal  decay  involving  both  teeth  of  the  left  side.  Teeth 
presenting  cavities  to  the  grinding  face,  as  here  seen,  will  invariably 
be  found  scooped  out,  and  overhung  by  unsupported  enamel.  To 
fully  uncover  such  cavities,  no  instrument  is  better  than  the  chisel, — 
the  operator  simply  cutting  away  the  operculum,  directing,  where 
possible,  the  greatest  breadth  of  the  cut  inward ;  such  manner  of 
cutting  is  expressed  upon  the  opposite  side  of  the  diagram,  where, 
as  is  seen,  the  cavities  are  fully  exposed  upon  the  sides  of  inclined 
planes,  while  the  anterior  faces  of  the  teeth  are  not  at  all  disturbed, 
the  cavities  being  put  into  a  position  and  aspect  in  which  they  may 
be  esteemed  as  simple  and  without  complication. 

Complications. — A  first  complication  may  be  described  as  a 
proximal  cavity  associated  with  a  second  occupying  the  sulcus 
found  on  the  grinding  face  of  these  teeth.  Here  a  plan  pursued  by 
many  consists  in  exposing  the  first  cavity  as  just  directed,  and,  this 
accomplished,  preparing  the  second  precisely  as  in  any  simple 
crown  cavity.  If  both  are  found  entirely  separate,  perfectly  healthy 
dentine  lying  between  them,  they  may  be  treated  as  distinct  cavi- 
ties ;  if,  on  the  contrary,  there  is  found  to  be  the  slightest  associa- 
tion, they  are  joined  together  by  cutting  out  the  septum  which  re- 
lates them. 

A  second  complication  is  found  in  the  existence  of  that  extent  of 
decay  which  has  so  weakened  the  front  or  back  wall  of  the  tooth  as 
to  make  the  removal  of  such  wall  necessary.  Such  a  condition  is 
unfortunate,  as  it  renders  the  operation  of  filling  more  difficult, 
except,  indeed,  to  the  experienced,  who  are  able  to  adopt  the  plan 
of  making  what  is  called  a  contour-filling, — that  is,  building  up  with 
metal  the  part  lost.  To  prepare  such  a  tooth  for  filling,  the  operator 
finds  himself  compelled  to  cut  wherever  the  disease  may  lead  him. 
This  he  does,  using  the  chisel, — chipping  away,  little  by  little,  the 
weak  parts,  desisting  only  when  the  evidences  of  disease  are  passed. 
Commonly,. teeth  so  decayed  are  found  with  the  pulps  exposed  ;  if 
this  should  not  be  the  case  in  any  particular  instance,  the  question 
of  how  the  required  filling  is  to  be  retained  becomes  of  all  con- 
sideration in  the  cutting  of  the  cavity,  the  answer  mostly  existing 
in  the  formation  of  retaining  points.  These  are  points  or  slots 
cut  out  of  the  dentine,  allowing  places  of  anchorage  ;  fillings  in 
such  teeth  being  made — when  ffold  is  used — of  that  form  known  as 


LOCAL   TREATMENT  OF  DENTAL   CARIES. 


303 


the  adhesive  ;  it  being  remembered  that  it  was  remarked  of  gold 
thus  prepared  that  it  could,  with  all  facility,  be  built  upon  the  sur- 
face of  a  metal  dollar. 

Still  another  complication  met  with  occasionally  consists  in  cavities 
meeting  in  the  middle  from  either  proximal  surface.  Such  cavi- 
ties are  treated  by  cutting  away  with  the  chisel  all  the  overlying 
grinding  surface,  thus  making  a  common  cavity,  which  occupies 
perhaps  the  whole  body  of  the  tooth.  Thus  exposed,  this  common 
cavity  is  excavated  and  cleansed  precisely  as  though  it  were,  what 
indeed  it  has  become,  a  deep  crown  cavity.  (See  diatrices.)  Such 
a  cavity  necessitates  contouring. 

The  most  common  form  of  decay  found  in  the  bicuspid  teeth, 
excepting  the  proximal,  is  that  running  in  the  sulcus  between  the 
two  cusps.  Where  this  is  simple,  it  is  prepared  for  filling  by  ream- 
ing it  out  at  either  extremity  with  a  delicate  rose  drill,  and  con- 
necting the  two  drill-holes  by  the  employment  of  the  excavator  or 
chisel. 

A  modification  in  this  single  groove  is  frequently  seen  in  a  middle 
point  of  division  entirely  healthy.  If  such  septum  is  of  any  size,  it 
maybe  allowed  to  remain,  and  each  cavity  be  reamed  out  separately. 

Fig.  8o. 


BIB 


^aarfly^^''' "''  1"™"!'""'^ 


luMMiU 


MMmm 


Form  of  Files  used  in  separating  the  Molar  ieeth. 


When,  however,  the  slightest  doubt  exists  as  to  its  integrity,  it  is 
much  the  safer  plan  to  remove  it,  thus  cutting  the  two  cavities 
into  one. 

We  refer  now  again  to  the  diagram.  Fig.  18,  and  observe  the 
relation  of  the  proximal  faces  of  the  first  and  second  molars  as  seen 
on  the  left  side.  These  teeth,  while  presenting  at  the  surface  a 
healthy  aspect,  are  yet  found  to  have  cavities  midway  of  this  face,  and 
which,  as  thus  situated,  have  only  been  discovered  by  the  insinuated 


304  ORAL  DISEASES  AND  SURGERY. 

point  of  a  delicate  excavator,  or,  what  is  more  likely,  the  passage  of 
a  silk  thread.  Referring  now  to  the  opposite  side,  these  cavities 
are  found  exposed.  This  is  accomplished  either  by  the  chisel,  or 
otherwise  by  files  purposely  prepared  to  make  such  a  cut  so  far  back 
in  the  mouth  without  interfering  with  the  lips.  Fig.  85  represents 
such  files.  The  cavities,  before  unseen,  are  now  exhibited  upon  the 
sides  of  the  inclined  planes,  and  fillings  placed  in  them  are  recognized 
to  have  surfaces  that  must  be  self-cleansing. 

Passing  to  the  grinding  surface  of  these  same  teeth,  cavities  of 
decay  are  seen  running  out  over  the  lateral  walls.  The  excavation 
of  these  consists  simply  in  following  the  sulci  wherever  they  may 
lead,  bearing  in  mind  the  fact  that  the  excavation  is  to  be  of  such 
character  as  provides  for  the  retention  of  the  filling ;  that  is,  that  at 
all  aspects  it  is  to  have  a  wall  slightly  concave.  Sometimes,  when 
much  depth  has  been  attained  by  that  portion  of  the  decay  in  the 
crown,  and  perhaps  as  well  that  upon  the  side, — the  connecting 
sulcus  being  of  slight  signification, — it  is  good  practice  to  scoop  out 
this  intervening  portion,  without  regard  to  the  shape  of  its  walls, 
and  carr}''  the  adhesive  gold,  arch-like,  into  and  over  it  from  one 
plug  to  the  other. 

Passing  now  to  the  proximal  faces  of  the  second  and  third  molars, 
left  side,  attempt  has  been  made  by  the  artist  to  represent  cavities 
in  these  teeth  prepared  for  contour-fillings, — a  plan  of  preparing  all 
proximal  cavities  of  any  extent  in  the  bicuspidati  and  molars  grow- 
ing rapidly  into  general  favor,  and  certainly  productive  of  the 
ability  to  make  beautiful  operations.  First,  it  is  seen  that  a  sepa- 
rating file,  slightly  V-shaped,  has  been  passed  between  the  teeth. 
Next,  the  cavities  have  been  excavated,  being  cut  directly  down 
from  the  crown  surface,  and  have  been  so  shaped  that  in  putting  in 
the  metal  the  operator  works  directly  from  this  crown  surface. 
These  teeth  are  so  excavated  that  when  filled  it  is  proposed  to  re- 
store fully  the  portion  lost. 

The  preparation  of  the  teeth — molars  or  others — for  contour-fill- 
ings must  find  direction  in  experience.  It  is  to  be  recognized  that 
the  idea  and  intention  are  to  repeat  in  metal  what  has  decayed 
or  been  cut  away.  In  proportion  as  the  part  removed  has  been 
extensive,  so  must  it  be  recognized  that  proportionate  difficulty  will 
exist  in  securing  fixedness  for  the  filling.  Contour-fillings,  save  in 
exceptional  cases,  should  possess  inclined  surfaces.  A  filling  which 
represents  the  surface  of  an  inclined  plane  has  been  amply  demon- 
strated by  experience  to  be  the  better  kind. 


LOCAL    TREATMENT  OF  DENTAL    CAEIES.        305 

In  excavating  a  cavity  of  any  class,  certain  rules  are  to  be 
observed  and  practiced : 

1.  A  cavity  must  have  such  exposure  as  shall  afford  room  to 
introduce  the  filling  properly. 

2.  Walls  are  to  be  made  as  perpendicular  as  the  case  will  admit  of, 
and  the  margin  of  a  cavity  is  to  be  at  right  angles  with  the  sur- 
rounding surface. 

3.  The  orifice  of  a  cavity  is  to  be  without  fissures  or  irregularities 
wherever  these  may  be  avoided;  must  have  a  firm  decided  margin, 
and  must  be  supported  solidly  by  the  underlying  dentine.  Rough- 
ness or  brittleness  in  the  edges  of  a  cavity  is  most  objectionable. 

4.  In  excavating  a  tooth,  regard  is  to  be  had  to  the  proximity  of 
the  pulp.  A  pulp  is  not  unnecessarily  or  carelessly  to  be  exposed, 
nor  to  be  too  closely  approached  ;  for  if  the  first,  the  case  is  immedi- 
ately changed  from  simple  to  complicated  ;  if  the  latter,  the  organ 
might  eventually  become  chronically  inflamed,  and  die,  as  a  result 
of  the  thermal  irritation  arising  from  the  presence  of  the  filling. 
Neither  is  it  permissil)le  to  file  or  chisel  a  tooth  too  freely,  except 
where  regard  is  had  to  the  density  of  the  organ.  A  tooth  of  very 
loose  texture  will  not  uufrequently  have  an  inflammation  of  the 
dentine  and  pulp  provoked  by  the  removal  of  even  a  slight  portion 
of  its  enamel,  while,  on  the  contrary,  a  tooth  of  very  dense  structure 
may  commonly  be  cut  with  considerable  impunity. 

5.  In  cavities  having  radii  running  from  a  common  centre,  which 
radii  may  not  with  propriety,  on  account  of  their  extent,  be  included 
in  a  single  round  hole,  care  is  to  be  observed  that  each  extremity  be 
rounded,  never  being  allowed  to  retain  its  natural  sharpness  or 
fissure-like  aspect.  Crown  fillings  fail  more  frequently  from  the 
non-observance  of  this  rule  than  from  perhaps  any  other  cause. 

In  the  process  of  excavating  the  teeth,  the  practitioner  will  re- 
quire, besides  the  instruments  mentioned,  a  syringe  for  washing 
away  the  debris,  and  a  mouth-mirror,  to  be  used  either  for  casting 
additional  rays  of  light,  or  showing  him  more  conveniently  the  cavity 
at  which  he  may  be  working.  Of  the  two  mirrors  exhibited,  the 
form  represented  in  Fig.  86  is  the  most  desirable.  Syringes  are  of 
various  construction.  Fig.  88  represents  one  made  with  a  hand  bulb 
of  rubber.  It  is  to  be  commended  for  a  simplicity  of  construction 
which  does  not  allow  it  easilv  to  get  out  of  order. 


20 


306    '  ORAL   DISEASES  AND   SURGERY. 

Fig.  86.  Fio.  87. 


Fig. 


Fig.  80. 


CHAPTER    XIII. 

LOCAL    TREATMENT    OP    DENTAL    CARIES. 

INTRODUCTION  OF  THE  FILLING. 

The  instruments  required  for  introducing  a  filling  of  gold  will 
viu'y  necessarily  somewhat  with  the  position  of  the  cavity  to  be 
filled,  and  the  character  of  the  metal  used, — whether  adhesive  or 
non-adhesive. 

A  filling  of  non-adhesive  gold  is  made  on  the  principle  of  wedging. 

A  filling  of  adhesive  gold  is  made  on  the  principle  of  interdigi- 
tation,  or  welding  of  the  particles. 

To  use  the  first  form  of  gold,  wedge  points  are  employed.  Such 
points,  as  for  sale  in  the  depots,  are  found  of  every  variety  of  curve. 
A  skillful  hand,  however,  is  best  served  in  the  forms  represented  in 


Fig.  f'O. 


Fio.  91. 


Plain-pointed  plii 


Serrated  points. 


the  diagram.  Fig.  90,  and  in  a  single  modification  where  the  wedge 
is  at  right  angles  with  the  shaft.  A  wedge  plugger  may  be  slightly 
rough  on  its  surface. 

To  employ  the  adhesive  gold,  instruments  with  points  more  or 
less  serrated  are  to  be  preferred.  These  serrations  require  to  be  kept 
very  smooth  on  their  planes,  otherwise  the  metal  is  pulled  away 
quite  as  rapidly  as  it  is  attached.  Fig.  91  exhibits  points  of  serra- 
tion magnified. 

The  handle  of  a  plugging  instrument  is  to  be  round  or  octagonal, 
and  so  roughened  that  the  hand  shall  hold  it  firmly,  while  the  blade 

(307) 


308  ORAL   DISEASES  AND   SURGERY. 

is  to  be  of  a  temper  which  allows  of  the  employment  of  the  neces- 
sary force  without  danger  either  of  breaking  or  bending.  These 
instruments  have  of  late  been  brought  to  such  perfection  by  the 
makers  that  the  operator  need  not  hesitate  to  receive  them  as  sup- 
plied. The  temper,  at  the  point,  is  to  be  of  straw  color,  and  from 
this,  u])  to  where  substance  gives  strength,  it  is  to  be  purple. 

As  dryness  is  essential  to  the  integrity  of  a  plug,  we  digress  at 
this  point  to  review  the  means  equivalent  to  sucli  end. 

Napkin)^. — Answering  in  all  ordinary  cases  we  have  the  napkin. 
A  dental  napkin  is  an  oblong  square  of  linen,  varying  in  size  to  suit 
the  idea  of  the  operator;  dimensions  which  will  be  found  conve- 
nient are:  length,  twelve  inches;  breadth,  three.  In  applying  this 
napkin  to  the  upper  denture,  it  is  folded  upon  it.self  in  part  obliquely, 
until  one  end  is  brought  to  a  point.  Beginning  with  this  point,  the 
linen  is  laid  delicately  and  smoothly  between  the  gums  and  cheek, 
being  carried  backward  or  forward  according  as  the  initial  end  may 
have  been  placed,  until  turning  into  the  mouth  at  a  convenient  dis- 
tance from  the  tooth  to  be  operated  upon,  it  is  made  thus  to  envelop 
the  organ,  being  supported  on  either  side  of  the  arch  by  the  fingers 
of  the  left  hand. 

Applied  to  the  lower  denture,  the  napkin  is  first  folded  upon  itself 
into  a  ribbon-shape  of  an  inch  in  width  ;  second,  the  initial  extremity 
is  back-folded  until  a  pad  is  made  which  shall  correspond  in  length 
to  its  width,  that  is,  being  an  inch  each  way.  This  pad  is  to  be 
laid  upon  the  floor  of  the  mouth  directly  back  of  the  incisor  teeth, 
thus  covering  the  orifices  of  the  ducts  of  both  the  submaxillary  and 
the  sublingual  glands  :  from  this  point  it  is  carried  around  the  arch 
into  the  vestibule  as  required. 

To  hold  the  floor  pad  firmly  in  place,  as  is  demanded,  various 
plans  are  adopted.  The  most  common  one  is,  where  the  tooth  to 
be  filled  is  upon  the  right  side  of  the  jaw,  for  the  operator  himself 
to  fix  it  by  the  thumb  of  the  left  hand  while  the  index-finger  is 
extended  over  the  part  occupying  the  vestibule.  Where  the  tooth 
to  be  shielded  is  upon  the  left  side,  the  index-finger  of  the  right  hand 
of  the  patient  is  employed,  the  three  remaining  fingers  being  doubled 
out  of  the  way  beneath  the  chin. 

As  the  encroachment  of  the  saliva  constitutes  about  the  most  trou- 
blesome oflense  in  dental  operations,  ingenuity  has  been  exercised 
to  its  utmost  for  its  control.  Fig.  92  represents  a  tongue-holder 
devised  by  Dr.  J.  Foster  Flagg. 


LOCAL    TBEATMENT  OF  DENTAL    CARIES.        309 
Fig.  92. 


"It  will  be  found  that  the  use  of  this  instrument  will  insure  addi- 
tional facility  to  the  operator,  and  maintain  the  tongue  in  position 
with  perfect  comfort  to  the  patient,  producing  no  fatigue,  no  un- 
pleasant sensations,  and  even  removing  all  desire  to  resist  constraint. 
After  introducing  a  fold  of  napkin,  or  a  small  piece  of  muslin, 
under  the  tongue,  and  then  covering  that  organ  by  l^ack-folding  the 
napkin,  or  placing  another  small  piece  of  muslin  upon  it,  the  holder 
should  be  put  in  position  nearest  to  the  side  where  it  is  proposed  to 
operate,  and  the  patient  be  requested  to  retain  it  thus  by  means  of 
the  inglit  hand  if  the  cavity  be  on  the  left  side,  and  the  left  hand  if 
the  cavity  be  on  the  right  side,  the  elbow  resting  upon  the  arm  of 
the  operating-chair." 

Another  instrument,  a  modification  on  an  ingenious  invention  of 
Dr.  Hawes,  is  that  which  bears  the  name  of  Morrison's  compressor. 
(See  Fig.  93.)     The   diagram  fully   illustrates  its   working.     The 

Fig.  93. 


Morrison's  compressor. 


napkin,  being  put  into  place  beneath  the  tongue,  is  held  by  the  bars 
of  the  curve,  the  cup  receiving  the  chin,  the  ratchet-work  approxi- 
mating and  holding  the  two  parts  in  the  required  relation.     A  later 


310 


ORAL  DISEASES  AND  SURGERY. 


instrument  of  this  same  character  is  one  designed  by  P.  T.  Smith, 


Fig.  94. 


Siiliva-puiiip. 


D.D.S.,  the  variation  consisting  in 
the  sliding  of  the  bar  which  supports 
the  compress,  and  in  an  ability  to 
change  the  position  of  the  chin-rest. 
A  still  later,  is  a  porcelain  tongue 
thimble,  which  highly  commends 
itself. 

The  annexed  cut  represents 
"  a  saliva-pump  and  tongue-holder 
combined,  the  invention  of  Dr. 
Dibble.  The  object  of  this  instru- 
ment is  to  facilitate  the  operation 
of  filling  teeth  of  the  lower  jaw 
by  keeping  the  mouth  free  from 
saliva,  and  as  a  means  of  holding 
the  tongue  away  from  the  teeth ; 
also  a  means  of  supporting  the 
upper  jaw,  and  so  assisting  the 
muscles  which  keep  the  mouth 
open,  the  application  of  which  will 
be  readily  understood  from  the  illus- 
tration. The  instrument  is  com- 
posed of  coin  silver  heavily  plated 
with  gold,  and  hard  rubber.  A 
designates  the  plate  which  keeps 
the  tongue  away  from  the  teeth  ; 
B,  the  arm  which  supports  the 
jaw;  C,  the  silver  tube  and  base 
which  fit  over  the  jaw  ;  D,  the 
opening  where  the  saliva  enters  the 
tube  ;  E,  the  chamber  that  receives 
the  saliva.  A  vacuum  is  made  in 
the  saliva  chamber  by  the  pressure 
of  the  bulb  I,  thereby  causing  the 
saliva  to  flow  into  the  opening  D  ; 
H,  the  opening  where  the  saliva  is 
discharged  ;  Gr,  the  exhaust-valve. 
There  are  two  mouth-pieces,  one 
for  the  right  side  and  one  for  the 
left  side  of  the  mouth. 

"  The     instrument     is     readily 


LOCAL    TREATMENT    OF  DENTAL    CARIES.        311 


cleaned  externally  bv  means  of  a  brush,  soap,  and  water;  internallv, 
b}'  drawing-  soap  and  water  through  it.  It  must  not  be  laid  down  on 
its  side  after  using  until  emptied  of  saliva.  The  entire  length  of  the 
instrument  is  fifteen  inches." 

An  instrument  most  happily  serving  as  an  adjunct  to  the  man- 
aging of  a  napkin,  holding  in  place  pellets  of  spunk,  bibulous  paper, 
etc.,  is  an  extension-finger  devised  by  Dr.  J.  H.  McQuillen.  This 
consists  of  a  silver  shield  (see  Fig.  95)  (to  be  worn  upon  the  index- 
finger)  with  a  socket  on  the  under  surface,  in  whicli  a  steel  finger  B 
fits.      A  number  of  these  fingers  or  bits   bent  at  d liferent  angles 


Fig.  05. 


McQuillen's  extension-fingev. 


Taffs  tliinil.Ie. 


accompany  the  shield,  being  adapted  to  meet  the  various  require- 
ments. This  instrument  is  also  found  of  the  greatest  assistance  in 
fixing  mats  of  gold  in  position  during  the  process  of  filling,  doing 
away,  in  many  instances,  with  the  necessity  for  retaining  points. 

A  second  form  of  instrument  having  a  similar  signification  with 
that  just  described,  known  as  Taft's  thimble  and  extension,  is  repre- 
sented in  Fig.  96.  This  thimble  is  to  be  used  upon  the  index  or 
middle  finger  of  the  left  hand.  It  is  also  employed  to  aid  in  holding 
the  napkin,  paper,  spunk,  or  whatever  may  be  used  to  prevent  the 
encroachment  of  saliva.  The  point  of  this  instrument,  like  the  first, 
can  extend  into  the  mouth  where  the  finger,  either  on  account  of  its 
size,  or  for  want  of  length,  cannot  go.  It  may  also  be  used  to  hold 
down  a  piece  of  gold  until  it  is  made  fast  in  the  proper  position.  It 
will  likewise  be  found  a  convenience  with  which  to  reach  over  and 
draw  the  napkin  up  firmly  against  the  lingual  sides  of  the  teeth. 

A  form  of  compressor  for  the  Stenonian  duct,  the  invention  of 
Dr.  Rich,  and  figured  on  the  following  page,  is  thus  described  : 

"  This  forceps  and  spring  professes  to  accomplish  the  closure  of 
the  duct  more  perfectly  than  any  other  appliance.  The  spring,  with 
a  pad  of  bibulous  paper,  or  napkin,  prevents  all  flow  of  saliva, 
while  the  tip  is  free  to  yield  to  every  motion  ;  whereas  with  a  wad  of 
napkin  in  the  cheek,  the  lip  is  tight,  and  very  little  motion  frees 
the  duct,  allowing  the  saliva  to  flow. 


312 


ORAL  DISEASES  A.\W   SURGERY. 


"  In  use,  the  recurved  ends  of  the  forceps  fit  in  the  recess  of  the 

spring,  whicli  closure 
of  the  handles  will  ex- 
pand. Then,  having 
placed  the  pad  in  posi- 
tion,— exactly  opposite 
the  second  upper  mo- 
lar,— release  the  grasp 
on  the  handles,  the 
spring  will  close  and 
forceps  be  detached  at 
once.  An  outer  pad 
may  be  slipped  under 
the  spring  afterwards, 
if  desirable." 

An  operative  plan 
of  controlling  the  pa- 
rotid secretions  has 
been  suggested,  and 
perhaps  to  some  ex- 
tent practiced,  consist- 
ing in  placing  a  tempo- 
rary ligature  about  the 
ducts.  This  is  certainly 
to  be  opposed  as  an 
unsurgical  proceeding, 
and  one  which  might 
most  readily  eventuate 
in  stricture. 

Of  all  the  various 
appliances,  however, 
aside  from  the  napkin, 
designed  for  the  con- 
trol of  the  salivary  se- 
cretion, not  one  has 
seemed  to  meet  with 
so  universal  an  ap- 
proval as  what  is 
known  as  the  coffer- 
dam of  Barnura.  This 
consists  in  a  simple  sheet  of  thin  rubber,  prepared  for  the  purpose, 


LOCAL    TREATMENT  OF  DENTAL    CARIES.        313 

into  which  one  or  more  minute  holes  are  to  be  punched  for  the 
passage  of  certain  teeth  associated  with  the  proposed  operation. 
When  properly  applied,  even  a  lower  tooth  may  be  protected  from 
the  saliva  for  a  period  of  four  or  five  hours,  should  such  time  be  a 
requirement. 

In  applying  this  dam,  the  operator  starts  with  the  principle  that 
a  delicate  round  hole  is  to  be  made  in  a  sheet  of  rubl)er ;  this  is  to 
be  stretched  by  passing  the  diseased  tooth  through  it.  The  rubber 
thus  tightly  grasping  the  tooth  is  forced  beyond  the  place  of  decay, 
putting  the  cavity  in  a  water-tight  dam. 

Applying  this  dam  of  Dr.  Barnum  to  an  isolated  tooth,  an  oper- 
ator would  be  led  to  conclude  that  nothing  was  left  to  be  desired  ; 
passing,  however,  to  one  of  complicated  relation,  he  would  err  as  far 
on  the  other  side  in  inferring  it  to  be  without  value.  That  the  reader 
may  be  possessed  of  a  proper  appreciation  of  the  capabilities  of  the 
appliance,  attention  is  directed  to  the  communication  of  a  gentleman 
who  seems  to  have  had  all  necessary  experience  in  this  direction, 
J.  F.  P.  Hodson,  D.D.S.,  being  an  essay  offered  by  him  for  the 
consideration  of  the  First  District  Dental  Society  of  New  York.  It 
will  of  course  be  found  that  others  have  expedients  to  meet  the 
same  indications  varying  markedly  in  character.  These  expedients 
come  to  suggest  themselves  to  every  person  of  reasonable  ingenuity 
as  experience  widens,  but,  as  a  study,  the  suggestions  in  this  paper 
cannot  fail  to  afford  many  useful  hints  in  the  direction  of  the  use 
of  this  dam.     As  a  study  simply,  it  is  quoted. 

"  Experience,"  says  this  gentleman,  "  only  can  enable  one  to  judge 
as  to  just  which  cases  to  apply  this  dam.  As  an  operator  becomes 
more  and  more  skillful  through  practice  in  manipulation  with  it,  he 
will  find  the  cases  to  which  he  cannot  apply  it  becoming  fewer,  and 
in  the  course  of  time  discovers  that  whether  to  apply  the  dam  or  not 
to  any  case — perhaps  one  in  fifty  excepted — becomes  vierely  a  ques- 
tion of  expediency. 

"  I  seldom,"  he  continues,  "  use  the  dam  for  simple  cavities  in  the 
grinding  surface  of  superior  molars,  but  lay  a  narrowly-folded 
napkin  or  bilmlous  paper  along  the  gum  outside  instead.  I  do  use 
it,  on  the  other  hand,  in  almost  every  case,  for  the  lower  teeth,  and 
nearly  always  for  approximal  cavities,  wherever  situated. 

"  Two  or  three,  or,  in  extraordinary  cases,  more  teeth,  should  be 
embraced  by  the  rubber,  unless  the  tooth  operated  upon  is  standing 
isolated  from  the  rest.  The  holes  should  be  as  round  as  possible — 
as  a  sharp  angle   in   them   is  a  tear  suggested — and  very  small. 


3U  ORAL  DISEASES  AND   SURGES Y. 

though  varying  with  the  resiliency  of  the  rubber, — say  the  size  of 
an  ordinary  pin's  head  for  a  bieuspis,  and  in  this  proportion  for  the 
other  teeth.  The  distance  which  the  holes  should  be  apart  must 
be  a  matter  of  judgment  for  each  case.  Where  the  teeth  are  near 
together,  they  may  be  within  an  eighth  or  three-sixteenths  of  an 
inch  of  each  other.  Where  there  is  a  wedged  space  and  approximal 
cavity,  it  is  a  nicer  matter  to  determine,  as  you  must  have  sufficient 
rubber  between  the  holes  to  allow  for  both  teeth  being  embraced  so 
snugly  as  not  to  admit  of  leakage,  wliile  an  excess  of  rubber  would 
puff  up  between  the  teeth,  and  hide  that  essentially  important  point, 
the  cervical  edge  of  the  cavit}'.  After  the  holes  are  cut,  carry 
the  rubber  down  between  the  teeth  with  waxed  floss  silk,  being 
careful  to  place  the  silk  as  near  as  possible  to  the  edge  of  the  hole, 
otherwise  the  rubber  will  be  torn.  It  is  more  convenient  to  com- 
mence with  the  tooth  nearest  the  front  of  those  which  are  to  be 
embraced,  and  apply  to  each  one  back  of  it  successively,  till  all  are. 
encircled.  The  edge  which  now  stands  up  against  each  tooth  must 
be  turned  under,  to  prevent  leakage.  This  may  be  accomplished  by 
carrying  the  floss  tightly  again.st  the  approximal  surface  of  each 
tooth,  and  down  upon  its  neck;  then,  with  a  small  burnisher,  com- 
plete the  circuit  by  turning  the  edge  upon  the  buccal  and  lingual 
surfaces.  This  is  all  done  when  the  rubber  is  applied,  and  does  not, 
in  practice,  consume  one-quarter  of  the  time  that  it  takes  to  write 
it.  At  the  first  and  last  spaces  leave  the  floss,  to  prevent  the  slip- 
ping off  of  the  rubber. 

"  Incases  of  partially-developed  teeth,  or  those  whose  crowns  are  of 
too  conical  a  form  to  retain  the  rubber  unassisted,  special  appliances 
will  be  required.  Some  operators  suggest,  for  the  lower  teeth,  tying 
a  piece  of  twine  or  floss  around  the  tooth  over  the  rubber,  attaching 
a  small  weight  to  the  ends,  and  allowing  it  to  hang  down  out  of  the 
mouth.  This,  to  my  mind,  has  many  objections,  chief  and  conclu- 
sive among  which  is  the  fact  that  when  the  tooth  is  sufficiently 
developed  to  apply  this  string-holder,  I  can  entirely  dispense  with 
its  use,  and  depend  on  leaving  the  floss  between  the  tooth  and 
gum,  as  I  shall  hereafter  describe. 

"  The  following  method  I  much  prefer  to  the  string  and  weight 
above  mentioned.  Take  a  piece  of  annealed  iron  wire,  of  medium 
size,  and  twist  it  tighlly  around  the  tooth,  and  as  near  its  neck  as 
possible,  leaving  the  ends  half  an  inch  long,  and  projecting  from  the 
buccal  side  of  the  tooth  ;  lift  it  off  carefully,  and,  having  applied  the 
rubber,  hold  it  on  with  one  hand,  while  with  the  other  you  place  the 


LOCAL    TREATMENT  OF  DENTAL    CARIES.        315 


wire  ill  position  over  the  rubber,  holding  that  with  your  finger  till, 
with  a  large  plugger,  you  push  it  down  on  the  tooth  all  around, 
getting  it  to  catch  at  some  point,  if  possible  ;  then,  holding  it  down 
with  the  plugger  on  the  lingual  side,  push  the  projecting  ends  or 
'handle'  down  close  to  the  gum;  place  finger  or  thumb  upon  it,  and 
you  are  'master  of  the  situation.' 

"The  foregoing  applies  especially  to  partially  developed  inferior 
molars.  If,  as  is  often  the  case,  a  thick  lip  of  gum  projects  over  the 
posterior  part  of  the  grinding  surface,  and  is  too  stiff  for  the  rubber 
to  push  back,  I  excise  it  and  proceed  as  before.  lu  the  great  ma- 
jority of  cases,  however,  with  these  teeth,  there  is  no  difficulty  in 
causing  the  rubber  to  retain  its  place,  by  carrying  floss  silk,  single, 
double,  or  triple,  down  between  it  and  the  posterior  approximal 
surface  of  the  tooth  ;  and  if  there  be  a  tooth  in  front  of  it — Avhich  in 
such  cases  should  also  be  embraced  by  the  rubber — passing  the  floss 
forward  from  each  side,  and  making  it  l)ind  around  the  tooth  by 
crossing  it  between  the  two  anterior  to  the  one  operated  upon. 

"  But  when  these  teeth  are  so  little  developed  as  that  the  difficulty 
of  retaining  the  dam  upon  them  will  not  be  obviated  by  either  of  the 
just-described  methods,  I  employ  the  following  : 

Fig.  98. 


12  3 

"  (No.  7.)  Form  a  wide  clasp  of  thin  gold,  or  other  metal,  to  fit 
the  tooth,  rounding  the  ends  somewhat,  and  letting  them  slip  past 
each  other;  let  it  be  a  trifle  flaring  from  its  lateral  centre  to  each 
-edge.  The  lower  side  is  flared  because  that  portion  of  the  tooth 
which  is  below  the  gum  line  is  larger  than  that  above  it,  and  the 
upper  flare  is  to  retain  the  rubber ;  or,  if  preferred,  the  upper  flare 
may  be  represented  by  a  wire  soldered  around  the  edge.  (No.  3.) 
Slip  this  clasp  down  upon  the  tooth  as  far  as  possible,  letting  it 
penetrate  between  the  tooth  and  gum,  and  proceed  to  apply  the 
dam  to  this  clasp,  after  which  pack  the  space  between  the  tooth  and 
clasp  with  spunk,  for  the  purpose  of  damming  out  any  moisture 
from  that  direction;  when,  with  a  finger  upon  the  top  of  the  clasp 
as  a  security  for  its  retention,  proceed  to  accomplish  the  now  ren- 


316  ORAL  DISEASES  AND  SURGERY. 

dered  simple  operation  of  introducing  the  gold.  And  just  here  let 
nie  say  that  this  'spunk'  that  we  use  is  invaluable  for  stopping, 
under  pressure,  any  leak — unless  it  be  a  very  large  one — which  may 
occur  during  an  operation  from  an  inadvertent  puncture  of  the  rubber. 
I  do  not  wish  to  omit  mentioning,  at  this  point,  and  for  these  opera- 
tions, a  little  instrument  that  I  use  very  often.  It  is  simply  a 
broken  excavator  bent  into  the  shape,  or  nearly  so,  of  a  very  large 
but  short-turned  corkscrew  plugger,  the  curve  fitting  the  posterior 
surface  of  the  tooth,  and  the  part  resting  upon  the  gum,  a*t  that  point 
filed  to  a  flat  surface.  It  is  held  in  the  left  hand  throughout  the 
operation,  and  in  the  position  indicated,  there  being  one  for  each 
side  of  the  mouth.  It  is  very  valuable  in  those  cases  where  wo  have 
the  combined  difficulties  presented  of  a  very  unyielding  gum  and 
conical  shape  of  the  tooth's  crown. 

"At  least  as  difficult  cases  as  these  to  control  are  those  of  gum 
cavities,  whose  edges  are  below  the  gum  line,  and  for  them  I  have 
several  appliances,  according  to  their  position.  We  will  consider, 
first,  an  inferior  molar,  with  a  gum  cavity,  large  or  small,  upon  its 
buccal  surface.  I  have  for  such  two  or  three  clasjjS,  of  such  con- 
struction as  I  shall  immediately  describe,  with  sufficient  variation 
in  their  shapes  to  comprehend  the  more  pronounced  corners  and 
angles  of  all  molars. 

"(No.  6.)  This  appliance  is  an  open  clasp,  formed  from  clasp-gold 
or  steel,  with  the  ends  left  wide  and  heavy  on  the  lingual  side  of  the 
tooth,  which  ends  are  to  be  turned  outward  at  right  angles  to  the 
clasp,  for  a  length  of  say  three-sixteenths  of  an  inch,  leaving  a  short 
space  between  the  two.  A  hole  is  drilled  through  one  of  these  pro- 
jecting ends  for  the  easy  play  of  a  short  and  thick  screw,  and  a  thread 
cut  in  a  corresponding  hole  in  the  other,  to  engage  with  the  thread 
on  the  screw.  This  is,  as  is  apparent,  for  the  purpose  of  fitting  the 
clasp  tightly  to  the  tooth.  The  upper  edge  of  the  clasp  is  to  be  cut 
away  on  the  buccal  side,  leaving  it  the  width  of  an  eighth  of  an  inch 
or  less  ;  the  upper  side  of  this  turned  outwards,  and  the  lower  side, 
which  is  to  engage  with  the  neck  of  the  tooth,  finely  serrated.  On 
the  upper  side  of  this  buccal  portion  is  left  standing  a  little  ear- 
shaped  piece  with  a  dent  in  its  centre,  which  is  to  be  turned  down 
to  a  horizontal  position,  and  is  for  the  purpose  of  carrying  down  this 
portion  of  the  clasp,  under  the  pressure  of  an  instrument  held  in  the 
left  hand,  with  its  point  resting  on  the  ear-piece.  The  whole  clasp 
should  be  formed  in  such  a  manner  as  that,  when  in  position,  the 
lower  edge  of  this  buccal  side  shall  dip  slightly  below  the  correspond- 


LOCAL    TREATMENT   OF  DENTAL    CARIES.        317 

ing  edge  of  the  lingual  In  applying  it,  if  the  buccal  contour  of  the 
tooth  be  irregular,  the  clasp  should  be  fitted  somewhat  to  these 
irregularities  with  the  pliers  before  putting  on  the  rubber;  then 
apply  the  dam,  put  on  the  clasp,  and,  after  stretching  the  rubber  to 
the  edge,  hold  it  and  the  clasp  in  position  while  you  turn  the  screw 
on  the  lingual  surface  and  snugly  fit  the  clasp.  It  will  be  found 
necessary,  in  most  cases  of  this  nature,  to  hold  the  clasp  down,  as 
before  described,  with  an  instrument,  throughout  the  operation, 
though  it  may  sometimes  be  dispensed  with.  This  is  more  espe- 
cially adapted  to  gum  cavities  in  those  teeth  whose  buccal  contour 
at  the  gum  line  is  either  very  convex  or  very  irregular. 

"  (No.  5.)  Where,  however,  the  tooth  presents  aflat  surface  at  this 
point,  I  have  a  clasp  of  thin  steel,  very  wide,  and  going  over  the 
tooth  from  lingual  to.  buccal  surface,  with  ver}''  delicate  teeth  cut  on 
the  extreme  ends,  which  are  turned  in,  as  shortly  as  possible,  to  a 
right  angle.  Opposite  the  cavity  the  clasp  is  cut  out,  leaving  the 
smallest  possible  rim  ;  the  external  edge  of  this  is  to  be  bent  up 
towards  the  clasp  till  that  portion  which  was  next  the  gum  is 
brought  to  a  little  above  a  right  angle  ;  the  inside  edge  of  the  rim 
is  to  be  serrated,  and  is  to  engage  with  the  tooth,  below  the  edge  of 
the  cavity.  On  the  outside  of  the  rim,  next  the  gum,  is  left  a  small 
ear,  precisely  similar  to  the  one  described  on  the  last  fixture,  and 
for  the  accomplishment  of  the  same  end.  (Xos.  5  and  4.)  This 
style  of  clasp  is  equally  applicable  to  labial  or  buccal  gum  cavities 
on  all  teeth,  with,  of  course,  the  shape  modified  to  suit  such  cases. 

"  For  the  front  teeth,  and  particularly  the  lower  ones,  there  are 
some  cases  which  this  will  not  reach.  For  such  I  employ  two  or 
three  patterns  of  the  following.  (No.  1  )  Cut  from  a  piece  of  plate, 
of  medium  thickness,  a  form  resembling  the  inverted  letter  V,  with 
a  square  top,  and  of  such  length  as  that,  when  laid  against  the  tooth 
with  the  ends  pointing  towards  the  gum,  they  shall  reach  nearly  to 
it  on  each  side ;  to  these  ends  solder  a  small  but  stiff  rim,  running 
in  front  of  the  tooth  at  a  slight  angle  downwards  to  the  main  piece, 
the  ends  of  the  latter  having  been  previously  bent  inward  some- 
what, in  order  to  freely  expose  to  view  the  cavity  between  them. 
In  the  square  top  of  the  main  piece  are  drilled  two  holes  for  the 
purpose  of  attachment  to  the  tooth.  The  whole  is  applied  by 
putting  on  the  rubber,  carrying  down  the  approximal  edges,  as  in 
all  similar  cases,  drawing  the  rubber  to  the  cervical  edge  and  super- 
posing the  holder  upon  it — after  looping  a  piece  of  floss  silk  through 
the  holes  in  the  top,  and  passing  the  loop  over  the  tooth,  and  tying 
firmly  to  place. 


318  ORAL  DISEASES  AND   SURGERY. 

"  Where  the  cavity  is  an  approximal  one,  and  extends  under  the 
gum,  the  wire  clasp  before  mentioned  may  be  made  useful  for  hold- 
ing the  rubber  and  gum  away  from  the  cavity,  by  threading  between 
the  teeth,  and  twisting  it  on,  after  the  rubber  has  been  applied;  or 
it  may  be  put  on  before  the  rubber,  leaving  the  twisted  ends  pro- 
jecting ;  and,  in  carrying  the  rubber  to  place,  pass  through  the  hole 
which  is  to  embrace  this  tooth  both  the  tooth  and  ends  of  the  wire, 
and  bring  the  wire  above  the  rubber  with  a  small  burnisher. 

"When  teeth  have  been  wedged  apart  for  the  purpose  of  filling 
approximal  cavities,  they  are  always  more  or  less  loose  and  tender, 
and  it  has  always  been  ray  practice  in  such  cases  to  insert  a  thin 
wooden  wedge  at  the  necks,  before  commencing  to  operate,  for  the 
double  purpose  of  keeping  them  firm  and  apart  while  operating. 
This  wedge,  when  the  dam  comes  to  be  applied,  may  be  left  in  its 
position,  and  the  dam  superposed  upon  it,  or  it  may  be  taken  out 
and  placed  over  the  rubber.  The  great  objection  to  the  latter 
method  has  been,  that  the  resiliency  of  the  rubber,  together  with 
the  movement  of  the  teeth  in  operating,  does  not  admit  of  a  simple 
wedge's  keeping  its  place.  This  difficulty  has  been  remedied  by  a 
little  device,  suggested  to  me  by  Dr.  Varney,  of  this  city,  and  which 
consists  in  inserting  between  the  wedge  and  rubber  a  T-shaped 
washer,  of  very  thin  metal,  the  long  arm  being  of  a  width  to  pass 
readily  between  the  teeth,  and  the  inside  of  the  short  ones  cut  to  fit 
the  buccal  corners  of  the  teeth  between  which  it  passes.  This 
appliance  is  also  of  great  value  for  exposing  all  approximo-buccal 
cavities. 

"  (No.  2.)  When,  however,  the  cervical  edge  of  the  cavit}'  is  so  far 
beneath  the  gum,  and  the  gum  on  either  side  of  the  approximal 
surface  is  so  hard  and  unyielding  as  that  this  method  shall  prove 
insufficient  to  surmount  the  difficulty,  recourse  is  found  in  the  fol- 
lowing: cut  a  strip  of  clasp  plate,  of  medium  thickness,  to  a  width 
approximating  that  of  the  lateral  diameter  of  the  tooth  ;  drill  two 
small  holes  across  and  near  the  end  ;  then  bend  the  strip  just  below 
the  holes  to  an  angle  of  foi'ty-five  degrees  or  thereabouts,  and  of  a 
sufficient  length  to  reach  across  the  space  and  to  the  cervical  edge  of 
the  cavity.  (In  special  cases, — for  instance,  if  the  crowus  are  long, — 
it  is  well  to  bend  up  at  a  slight  angle  this  end  for  the  one  thirty-second 
of  an  inch,  for  the  purpose  of  obtaining  the  essential  requisite  in  the 
premises,  viz.,  a  flat  surface  pressing  the  rubber  downward  and  at 
the  same  time  springing  against  the  neck  of  the  tooth  below  the 
cavity,  as,  if  these  are  not  complied  with,  the  teeth  will  not  be  held 


LOCAL    TREATMENT  OF  DEXTAL    CARIES.        319 

firnil}'  apart,  or  the  rubber  will  be  pressed  awa\^  from  the  neck  of  the 
tooth,  causing  leakage.)  This  end  is  to  be  beveled  to  an  edge,  and 
slightly  serrated,  to  prevent  it  slipping.  Now  apply  the  rubber,  and 
after  looping  a  piece  of  floss  silk  or  fine  wire  through  the  holes,  lay 
this  part  of  the  spring  against  the  approximal  surface  of  the  adjoining 
tooth ;  push  the  rubber  down  to  the  edge  of  the  cavity  ;  superpose 
upon  it  the  toothed  end  of  the  spring,  and  make  fast  by  tying  or 
wiring  tightly  around  this  adjoining  tooth.  As  has  been  hinted, 
this  appliance  will,  if  properly  made,  hold  the  teeth  firmly  wedged 
apart  while  filling, — a  very  essential  matter,  and  one  that  must  in 
such  cases  always  be  accomplished  in  some  manner,  as  the  dam 
tends  to  add  to  their  natural  inclination  to  return  to  the  position 
which  they  occupied  before  wedging. 

"The  matter  of  turning  under  the  edges  that  stand  up  against  the 
teeth  is  so  essential,  that  I  would  reiterate  the  necessity  of  its 
accomplishment  in  all  cases  and  around  each  tooth  ;  otherwise  there 
will  be  leakage  at  these  points,  the  unturned  edge  being  precisely 
analogous  to  an  open  valve  and  the  turned  edge  to  a  closed  one. 

"  While  upon  the  subject  of  gum  cavities  on  the  labial  surfaces  of 
the  incisors,  I  omitted  to  mention  the  following:  if  the  cervical  edge 
is  but  a  short  distance  beneath  the  edge  of  the  gum,  and  still  so  far 
as  that  the  dam,  unassisted,  will  fail  to  keep  its  place,  I  employ  an 
instrument — of  which  I  have  several  shapes — held  in  the  left  hand, 
for  the  purpose,  the  essential  part  of  which  is  simply  a  wide,  flat 
blade,  with  the  edge  on  its  end  hollowed  out  to  correspond  to  the 
contour  of  the  tooth's  neck;  this  concave  sharpened,  and,  if  thought 
proper,  finely  serrated,  it  will  be  found  more  convenient  to  hold,  if 
that  side  or  end  of  the  concavity  which  is  farthest  from  the  hand 
that  holds  it  is  left  longer  than  the  other.  The  particular  shape 
which  I  find  best  adapted  to  all  cases  is  that  of  an  enlarged  hatchet 
excavator. 

"  In  regard  to  the  quality  or  thickness  of  rubber  best  fitted  for 
our  purpose,  it  is  greatly  a  matter  of  taste  The  thinner  qualities 
require  more  skill  in  their  use  than  the  heavy  ones,  as  after  the 
application  of  the  former,  if  great  care  is  not  constantly  exercised, 
particularly  in  cavities  anywhere  near  the  gum,  it  will  be  stretched 
away  from  the  tooth,  and  the  operation  flooded.  On  the  other  hand, 
far  more  delicate  presentations  are  effected  through  it  than  by  the 
heavier;  besides  which,  it  passes  more  readily  between  teeth  which 
are  nearly  approximated :  indeed,  it  may  be  laid  down  as  a  rule,  in 
this  connection,  that  it  will  follow  floss  silk  into  any  position.     For 


320 


ORAL   DISEASES  AND   SURGERY. 


general  use,  however,  if  the  thinnest  were  numbered  1,  and  the 
thickest  4,  my  recommendation  would  be  number  2. 

"Any  sized  piece  may  be  used,  but  that  which  will  be  found  best 
for  most  cases  is,  perhaps,  four  or  five  by  six  inches.  And  though 
it  may  often  be  applied  in  such  a  manner  as  that  the  patient  may 
close  the  mouth  and  swallow,  it  Avill  generally  be  found  more  con- 
venient for  the  operator,  and  to  accord  better  with  tlie  taste  of  most 
patients,  to  spread  a  large  napkin  or  towel  over  the  shoulders,  for 
the  purpose  of  taking  up  the  saliva  as  it  leaves  the  mouth;  or  a 
double-valved  saliva-pump  may  have  its  nozzle  resting  in  the  mouth, 
the  rubber  tube  from  which  leads  to  the  spittoon,  when  an  occa- 
sional squeeze  of  the  air-chamber  will  effectually  keep  the  mouth 
free  from  saliva. 

"  The  ends  of  the  dam  may  be  held  l)ack  out  of  the  way  by -means 
of  a  little  fixture,  invented,  I  think,  by  Dr.  Coggswell,  which  is  simply 
an  elastic  band,  with  a  slide-clasp  on  each  end  for  seizing  the 
end  of  the  rubber,  and  a  contrivance,  in  addition,  on  one  end,  for 
drawing  the  band  tight,  the  latter  passing  around  the  head.  Another 
method  is,  to  catch  the  ruljber  with  small  hooks,  at  the  end  of  a 
piece  of  twine,  on  each  side,  and  crossing  the  ends,  to  which  are 
attached  small  weights,  on  the  head-rest  behind  the  head. 

"When  one  uses  the  dam  very  much,  he  will  find  that  the  con- 
stant pressure  of  the  floss  silk  under  the  nail  of  the  forefinger — 
which  is  the  one  most  used  in  applying  the  dam — will  keep  it  in  a 
constantly  sore  and  irritated  condition.  To  obviate  this,  I  cut  off 
an  ordinary  thimble,  so  that  it  shall  form  a  cap  for  the  end  of  that 
finger,  and  then  serrate  it  deeply  over  the  whole  end.  It  can  be 
taken  off  as  the  fingers  are  required  to  apply  the  dam  from  tooth  to 
tooth,  by  turning  that  finger  to  the  centre  of  the  hand,  and  reapplied 
in  the  same  manner  when  the  floss  is  taken  up." 

In  connection  with  this  paper  may  be  exhibited  an  appliance 
invented  by  Dr.  Forbes,  Fig.  99. 

Fig.  9U. 


"The  use  of  this  instrument  is  to  force  the  rubber  down  be- 
tween back  teeth,  evenly  to  the  necks,  without  tearing  it;  and  also 
to  pass  the  tying  cord   around   molars  more  pleasantly  than  can 


LOCAL    TREATMENT  OF  DENTAL    CARIES.  3:21 

be  done  with  the  fingers.  When  a  very  high  strain  is  needed, 
fix  the  cord  in  position  with  half  a  turn  around  the  button,  and 
tighten  it  while  pressing  the  points  of  the  fork  between  thumb  and 
finger." 

Operators  whose  experience  with  the  I'ubber  dam  has  been  large, 
recognize  that  few  cases  will  be  found  where  the  ligature  of  thread 
or  silk  cannot  be  made  to  fulfill  all  indications  in  the  way  of  securing 
it  in  position.  In  the  use  the  author  has  himself  made  of  this  means, 
he  has  certainly  been  able  to  accomplish  his  ends  without  exercise 
of  the  ingenuity  exhibited  in  the  paper  quoted:  as  a  study,  how- 
ever, the  suggestions  must  be  found  to  have  much  value  to  the 
inexperienced. 

A  cavity  before  prepared  to  receive  a  filling  is  to  have  a  direct 
drying;  that  is,  all  the  moisture  it  contains  is  to  be  absorbed.  To 
this  end,  what  is  known  as  bibulous  paper  is  commonly  used. 

A  means  widely  employed,  and  highly  extolled,  is  the  application 
of  dry  heat;  this  is  to  be  effected  by  the  use  of  an  air  syringe  with 
heated  bulb.  Fig.  100,  showing  such  an  instrument,  will  explain 
the  manner  of  its  use  at  a  glance. 

Fig.  100. 


Hot-air  syriuge. 


In  filling  the  proximal  face  of  a  tooth  when  the  napkin  is  de- 
pended on  to  keep  the  part  dry,  attention  is  necessarily  directed 
to  the  oozing  from  the  mucous  crypts  immediately  surrounding  the 
neck.  To  control  this,  some  operators  depend  exclusively  on  pads  of 
absorbing-paper  held  as  closely  as  possible  to  the  part.  A  mode 
more  convenient,  however,  and  more  reliable,  consists  in  passing  a 
wedge  of  soft  wood  between  the  cavity  and  the  gum,  allowing  it  to 
press  hard  against  the  latter.  Still  another  excellent  means  is  found 
in  including  the  neck  of  the  organ  in  a  ligature  of  heavy  silk  or 
other  thread,  tying  it  as  tightly  as  possible  and  thrusting  it. closely 
against  the  gum  out  of  the  way  of  the  operation.  Another  mode 
yet  is  found  in  the  cauterization  of  the  gum,  a  strong  solution  of 
iodine,  nitrate  of  silver,  or  chloride  of  zinc  being  used.  The  me- 
chanical means  suggested,  however,  will  be  found  the  most  satis- 

21 


322  ORAL  DISEASES  AND   SURGERY. 

factory  to  employ,  as  no  ulterior  ill  consequences  are  to  be  appre- 
hended. 

The  Filling. — Xon-adhesivo  gold  is  used  in  four  forms :  in  cylin- 
ders, in  plates  or  mats,  in  ribbons,  and  in  twists;  these  forms  being 
also  frequently  conjoined  in  a  single  cavity. 

To  make  a  cylinder,  a  sheet  or  portion  of  a  sheet  of  foil  is  folded 
upon  itself  until  a  ribbon  is  obtained,  which,  iu  width,  is  to  be  some- 
what greater  than  the  depth  of  the  cavity  in  which  it  is  to  be  used. 
The  ribbon  is  converted  into  the  cylinder  simply  by  rolling  it  around 
a  common  pin  or  brooch  ;  this  is  accomplished  in  a  moment  by  laying 
the  ribbon  lengthwise  along  the  index-finger  of  the  left  hand,  and, 
with  the  thumb  resting  upon  the  pin,  which  is  laid  across  the  initial 
extremity,  revolving  it  toward  the  palm. 

To  make  a  plate  or  mat,  first  convert  the  sheet  into  a  ribbon  as 
before,  of  such  varying  width  as  may  be  required;  next  back-fold 
into  the  required  length. 

To  make  a  ribbon,  proceed  as  has  been  directed. 

To  make  a  twist  or  rope,  first  convert  the  sheet  or  portion  of  sheet 
into  a  very  loose  ribbon;  twist  this  now  upon  itself  cork-screw  fashion. 

Referring  now  to  individual  cavities,  which  will  serve  as  studies 
to  direct  the  ingenious  hand,  attention  may  first  be  given  to  such 
simple  forms  as  are  represented  by  round  holes, — cavities  alluded 
to  as  being  common  to  the  crowns  and  sides  of  the  molar  teeth  and 
to  the  posterior  faces  of  the  incisors.  To  fill  cavities  of  this  class, 
the  cylinder  naturally  suggests  itself.  Selecting  one  of  a  size  which 
may  be  carried  readily  to  the  bottom,  it  is,  after  being  placed, 
to  be  laterally  expanded  by  a  wedge  plugger  carried  through  its 
centre,  or  otherwise  may  be  condensed  in  mass  against  the  wall  of 
the  cavity.  The  space  thus  made  is  to  be  filled  by  a  second  cylinder 
of  convenient  size,  the  wedging  to  be  repeated,  and  the  introduction 
of  cylinders  to  follow,  until  no  more  space  may  be  obtained. 

Plates  are  found,  in  the  beginning  of  an  operation,  to  conveni- 
ently replace  the  cylinder  where  crown  cavities  are  large  and  of  more 
or  less  irregularity  in  form.  They  are  used  precisely  as  the  cylinder, 
being  carried  into  position  by  means  of  the  foil-carrier,  and  con- 
densed carefully  and  accurately  against  the  immediately  neighboring- 
wall.  The  plates  following  the  first  may  either  be  arranged  around  the 
cavity,  thus  making  as  it  were  a  gold  cylinder  into  which  cylinder 
after  cylinder  as  before  directed  is  wedged,  or  one  plate  may  be 
condensed  against  its  fellow  until  in  this  way  the  cavity  is  full. 


LOCAL    TREATMENT  OF  DENTAL    CARIES.        323 


Filling  a  cavit}^  with  the  ribbon,  although  highly  Fia 
extolled  by  many,  is  associated  with  much  more  trou- 
ble than  the  use  either  of  cylinders  or  plates.  To 
manipulate  gold  so  prepared,  the  operator,  after 
carrying  the  initial  extremity  to  the  bottom  of  the 
cavity  and  fixing  it  by  any  convenient  means,: — generally 
by  holding  it  with  an  instrument  held  in  the  left  hand, 
or  confiding  the  task  to  an  assistant, — folds  upon  this, 
first,  layer  after  layer,  making  the  bend  at  such  distance 
above  the  orifice  of  the  cavity  as  considers  the  con- 
densation to  which,  later,  it  is  to  be  subjected,  and 
which,  if  properly  done,  is  to  afford  a  solid  surface 
that  shall  not  be  sunk  below  the  margin  when  the 
necessary  filing  and  polishing  shall  have  been  com- 
pleted. 

Twists  or  ropes  are  used  precisely  as  the  ribbon, 
fold  after  fold  being  bent  and  carried  into  a  cavity  until 
no  more  may  be  received.  It  is  more  common  to  con- 
fine the  use  of  the  rope  to  small  cavities,  such  as  are 
found  on  the  proximal  faces  of  the  anterior  teeth, 
although  operators  are  met  with  who  employ  gold  in 
such  form  exclusively. 

A  modification  on  the  use  of  the  ribbon  and  rope,  as 
just  described,  consists  in  wedging  the  centre  during 
the  progress  of  the  filling.  The  operator  first  gets  his 
cavity  loosely  filled  ;  then,  leaving  the  rope  as  related 
with  the  last  fold,  he  wedges  the  gold  against  the  parietes 
of  the  cavity.  This  secondaiy  cavity  is  then  filled  by 
turning  the  rope  into  it,  as  in  the  first  instance. 

Another  study,  which  may  serve  as  the  demonstra- 
tion of  a  second  class  of  fillings  made  of  non-adhesive 
gold,  are  the  cavities  in  the  anterior  teeth,  proximal 
faces.  As  the  filling  of  all  such  cavities  is  on  a  common 
principle,  we  will  take  the  incisor.  Fig.  78,  right  side, 
as  seen  prepared. 

To  fill  this  tooth, — being  made  ready  as  under- 
stood,— the  operator  takes  a  leaf  of  gold,  preparing  with 
it,  besides  a  rope,  a  number  of  plates.  The  plates 
he  arranges  upon  his  tray  or  table,  having  various 
sizes,  which  he  has  laid  in  such  convenient  rotation 
that,  without  search,  he  may  be  able  to  pick  up  such 
size  as  required.  The  rope  may  be  cut  into  small 
pieces.     The  gold  thus  made  ready,  the  next  require-      Foii^carner. 


324 


ORAL  DISEASES  AND   SURGERY. 


ments  are  the  necessary  instruments.  Fig.  102  exhibits  a  set  of  plug- 
gers,  designed  b}"  Dr.  W.  G.  Redman.  Possessing  these  instruments, 
an  operator  will  find  himself  able  to  introduce  and  pack  cyJinders, 
plates,  and  ropes  in  the  various  cavities  to  which  they  are  found 
adapted. 

"  These  cuts  represent  thirty  of  the  most  approved  points.  They 
can  be  made  with  handles  to  suit  the  purchaser.  A  half-inch  ivory 
or  ebony  handle  is  recommended.  Nos.  1  to  1  (serrated-foot  instru- 
ments) are  lateral  condensers  for  all  cavities.  Nos.  8  to  11  (smooth- 
foot  instruments)  are  used  in  the  same  cavities  and  in  the  same 
manner,  but  not  until  the  cavities  are  nearly  full.  Nos.  12  to  24  are 
all  approximal  condensers.  No.  25  is  for  anterior  approxiraal 
cavities,  molars  and  bicuspids.  No.  26  is  for  posterior  approximal 
cavities,  molars  and  bicuspids.     Nos.  27  and  28  are  for  crown  cavi- 

FiG.  102. 


10    11    12    13    14    15    16 


i' )  n  B"3 


23    24    25    26    27    28     29    30 

ties,  upper  molars  and  bicuspids.     Nos.  29  and  30  are  for  crown 
cavities,  lower  molars  and  bicuspids." 

To  fill  the  tooth  selected,  the  operator  would  take  up  with  his  foil- 


LOCAL    TREATMENT  OF  DENTAL    CARIES.        325 

carrier  a  plate  of  gold  of  a  size  suited  to  an  easy  introduction  into  the 
cavity.  This  plate  it  is  designed  to  place  firmly  against  the  neck- 
surface  of  the  cavity.  To  so  direct  and  place  it,  any  of  the  instru- 
ments, Nos.  t,  11,  2Y,  or  28,  might  be  employed.  The  first  piece  in 
position,  a  second  plate  is  to  follow,  being  introduced  in  like  man- 
ner and  consolidated  against  the  first.  Sometimes,  however,  and 
particularly  where  the  labial  wall  of  the  cavity  is  delicate,  it  is 
found  best  to  lay  this  second  plate  against  this  surface,  obtaining 
thus  increased  security  against  fracture.  Plate  after  plate  may 
now  be  added  until  the  cavity  is  full,  or,  if  preferred,  the  cut 
rope  may  be  used,  piece  after  piece  being  carried  and  wedged  into 
place. 

Another  plan  of  using  the  plates  in  cavities  of  this  character  con- 
sists in  first  lining  with  them  the  circumference  and  afterwards 
wedging  the  cut  rope  into  the  centre. 

Still  another  plan  that  is  found  at  times  convenient  consists  in 
placing  one  plate  against  the  neck-wall,  and  a  second  in  that  portion 
of  the  cavity  nearest  the  cutting  edge  of  the  tooth,  wedging  now  the 
cut  rope,  or  other  plates,  between  these. 

Another  plan  still  is  found  in  using  a  twist  or  rope  of  gold,  as 
directed  in  the  case  of  crown  cavities,  turning  into  the  cavity  layer 
after  layer,  until  no  more  can  be  entered.  This  formerly  was  the 
almost  universal  practice,  being  now,  however,  replaced  by  adhesive 
foil,  a  means  shortly  to  be  described. 

In  operating  on  a  cavity  of  such  position  as  we  now  consider,  the 
head  of  the  patient  is  to  be  thrown  back,  the  mouth  looking  upward. 
The  operator  stands  at  the  right  side  of  the  chair,  while  the  fingers 
of  the  left  hand  support  the  tooth,  as  may  be  found  required  for  the 
comfort  of  the  patient. 

The  chair  upon  which  a  patient  sits  is  to  be  of  such  height  of  seat 
that  the  head  is  brought  on  a  level  with  the  breast  of  the  operator. 
For  such  purpose  there  is  the  greatest  variety  of  construction.  (See 
Catalogues.*)  A  head-rest,  applicable  to  almost  any  chair,  and 
which  will  be  found  of  every  desired  convenience  to  the  army  sur- 
geon and  to  the  practitioner  who  may  not  desire  to  purchase  a  costly 
chair,  is  an  invention  of  Dr.  0.  C.White.     This  rest   "makes  its 


*  Catalogues  containing  illustrations  of  almost  every  instrument  and  appli- 
ance used  in  operations  connected  with  tlie  teeth  are  to  be  obtained,  free 
of  cost,  by  addressing  any  one  of  the  prominent  manufacturers  of  dental 
iroods. 


326 


ORAL  DISEASES  AND   SURGERY. 


own  fastening  to  almost  any  style  of  chair,  sofa,  lounge,  or  settee. 

It  has  full  movement  in 
^^^  all  directions,  on  a  scale 

for  a  tall  person  Or  for 
a  child,  and  is  securely 
fastened  by  turning  a 
single  thumb-screw." 

The      accompanying 
cut  represents  the  rest 
applied  to  a  common  of- 
fice-chair,   with    dotted 
lines  showing  its  movements  ;   and 
the  rest,  on  the  same  scale  of  size, 
folded  up,  to  occupy  but  little  space, 
either  for   transportation  or  to  lay 
aside. 

Weight,  4|  pounds. 
Upon  the  operating-tray  should 
always  be  found  pellets  of  bibulous 
paper  and  one  or  two  twists  of  cot- 
ton. A  small  bottle  of  chloride  of 
zinc,  or  of  Monsel's  solution  of  the 
persulphate  of  iron,  should  also  be 
within  convenient  reach  in  case  of 
slight  hemorrhage  from  an  accidental  pricking  of  the  gum.  Twists 
of  cotton  are  sometimes  found  of  great  service  in  slipping  between 
the  cavity  and  the  gum  when  the  napkin  is  used.  The  thumb  and 
finger  holding  the  tooth  will  also  fix  and  retain  the  twist.  It  is  to  be 
held  tightly  against  the  gum.  Even  more  convenient  than  the 
cotton  will  be  found  delicate  strips  of  wash-leather.  This  latter 
in  my  own  practice  I  have  come  to  prefer ;  it  absorbs  the  moisture 
fully,  and  is  more  easily  kept  clear  of  the  cavity,  should  this  be  near 
the  gum. 

Passing  to  still  another  study,  we  may  consider  the  anterior  proxi- 
mal surfaces  of  the  bicuspidati  and  molars.  Referring  to  the  dia- 
gram, Fig.  18,  it  will.be  seen  that  such  cavities,  when  properly  ex- 
posed, are  converted  into  those  of  very  simple  forms.  To  fill  them 
it  is  only  necessary  to  employ  the  mechanica-1  means  given.  Com- 
monly the  operator  commences  with  a  plate  which  he  fixes  against 
the  cervical  wall,  laying  plate  after  plate  against  this  first  one,  until 
the  cavity  is  full.     Where  the  cylinder  is  employed,  the  principle  of 


White's  Head-Rest 


LOCAL    TREATMENT  OF  DENTAL    CARIES.       327 

introduction  and  consolidation  will  be  seen  to  be  precisely  the  same. 
In  large  cavities  of  this  position,  it  will  be  found  an  excellent  plan 
first  to  bound  the  cervical  and  lateral  w^alls  with  plates,  and  after- 
wards wedge  the  cylinders  or  mats  within  this  golden  cavity. 

Posterior  proximal  faces  are  commonly  much  more  difficult  to  fill 
thah  the  anterior.  Such  difficulty,  however,  is  found  most  markedly' 
influenced  by  the  preparation  of  the  cavity  and  the  state  of  the 
boundaries  of  the  mouth  to  be  operated  in.  A  deep  narrow  arch 
with  the  labial  orifice  small  and  tense,  and  much  buccal  adipose 
tissue,  and  with  the  patient  unable  or  unwilling  to  assist  by  keeping 
the  mouth  well  open,  will  worry  the  most  skillful  and  experienced. 
On  the  contrary,  in  the  wide  mouth  of  free  and  lax  orifice,  little 
more  trouble  is  experienced  than  in  the  case  of  the  anterior.  Such 
cavities  are  filled  with  the  non-adhesive  gold  precisely  as  are  the 
anterior. 

The  use  of  matrices  in  the  construction  of  a  temporary  wall  for 
the  conversion  of  such  cavities  into  simple  holes  has  long  been  a 
favorite  means  employed  by  many  persons.  A  very  easy  and  always 
convenient  way  of  making  such  matrices,  and  one  which  the  auth'or 
has  employed  in  hundreds  of  cases  with  satisfactory  success,  con? 
sists  in  breaking  off  a  section  of  an  ordinary  separating  file  having  a 
free  or  uncut  surface,  and,  slipping  it  between  the  two  teeth,  wedging 
it  in  place.  This,  as  must  be  seen,  is  not  by  any  means  a  complete 
wall,  but  it  will  be  found  to  answer  a  most  excellent  end,  needing, 
indeed,  to  be  seconded  only  by  a  reasonably  skillful  touch  to  fulfill 
sufficiently  well  the  indications.  Such  matrices  are  most  conve- 
niently used  if  the  temper  is  first  removed. 

Another  mode  of  making  a  matrix  to  apply  to  an  approximal  in- 
clined plane  consists  in  taking  a  delicate  strip  of  silver,  and  after 
cutting  and  filing  so  that  it  shall  half  cover  the  cavity,  being  bulged, 
however,  just  over  it,  wedging  it  by  means  of  splints  of  boxwood  into 
place:  this  manipulation  forms,  as  is  seen,  a  limited  last  wall,  but 
such  wall  is  quite  sufficient  to  answer  the  ends. 

A  character  of  matrix  invented  by  Dr.  Louis  Jack  has  attained 
most  deserved  popularity.  A  description  of  its  use  given  by  the 
inventor  will  be  readily  understood  by  reference  to  the  cuts  which 
accompany.  When  cavities  are  of  such  extent  as  to  complicate 
very  much  the  process  of  introducing  and  fixing  the  gold,  these 
matrices,  from  what  might  be  termed  their  permanent  and  full  char- 
acter, will  be  found  not  only  to  spare  the  operator  much  fatigue,  but 
to  assist  materially  in  giving  form  and  solidity  to  a  plug. 


328  ORAL  DISEASES   AND   SURGERY. 

"The  difficulty,"  says  Dv.  Jack,  "of  correctly  filling  the  proximal 
surfaces  of  bicuspids  and  molars  is  so  universally  acknowledged, 
that  any  means  which  may  render  this  class  of  fillings  more  easy  of 
performance,  and  which  may  promise  more  certain  results  than  are 
usually  secured,  would  bo  regarded  by  every  one  as  an  important 
desideratum.  It  would  also  be  desirable  to  reduce  the  weariness 
which  is  inseparable  from  difficult  operations  on  the  proximal  sur- 
faces of  the  molars,  with  which  all  who  endeavor  to  be  faithful  are 
familiar.  My  own  experience  in  this  class  of  cases  has  been  excessive, 
and  the  constant  repetition  of  extensive  proximals  has  so  repeatedly 
exhausted  my  nervous  force  as  at  times  to  fill  me  with  despair.  It 
is  therefore  a  satisfaction  to  have  made  an  improvement  by  which 
much  of  this  difficulty  is  overcome;  by  which  the  introduction  of 
the  gold  has  been  rendered  much  simpler,  more  certain,  and  so  man- 
ageable that  I  must  now  let  others  have  the  full  benefit  of  my  expe- 
rience. 

"  It  will  at  once  be  granted,  at  least  by  those  who  have  learned 
to  appreciate  the  advantages  gained  by  the  use  of  the  mallet,  that  if 
we  had  a  fixed  boundary  or  wall  to  the  outer  side  of  the  cavity, 
having  the  form  required  to  give  a  proper  shape  to  the  surface  of 
the  filling,  and  a  sufficient  opening  to  freely  introduce  the  gold  to 
every  portion  of  it,  the  solid  filling  of  the  space  would  be  easily 
attainable. 

"  I  have  for  some  months  been  working  up  a  method  of  introduc- 
ing proximal  fillings  by  the  use  of  what  may  be  not  inappropriately, 
called  proximal  matrices.  It  will  be  necessary  first  to  describe  the 
preparation  of  the  cavity,  including  the  modifications  in  its  form 
required  to  adapt  it  to  the  application  of  the  means  to  follow.  1 
trust  to  be  excused  for  entering  at  some  parts  into  what  may  seem 
excessive  detail.  To  be  more  clearly  understood,  and  to  limit  the 
use  of  technical  terms  as  much  as  possible,  it  will  be  assumed  that 
considerable  caries  is  found  between  the  superior  first  molar  and 
bicuspid,  involving  both  teeth  on  their  proximal  surfaces,  extending 
from  beneath  the  gum  to  the  masticating  plate  of  enamel,  but  not 
involving  the  pulp.  Everything  herein  written  will  apply  to  the 
treatment  of  these  two  cases,  leaving  the  application  to  other  posi- 
tions to  be  made  by  the  reader. 

"  The  first  step,  in  case  the  teeth  are  in  close  contact,  is  to  separate 
them,  either  by  pressure,  or,  as  in  so  extensive  caries  as  is  under 
consideration,  by  a  parallel-sided  file  ;  and  from  this  slight  separation 
rapidly  and  freely  open  by  cutting  down  the  enamel  at  the  middle  of 


LOCAL    TREATMENT  OF  DENTAL    CARIES.        329 

the  spnce,  afterwards  increasing  somewhat  freely  with  the  chisel 
the  inner  portion  of  the  opening.  Another  plan  I  sometimes  pursue, 
where  no  fracture  of  the  masticating  plate  has  occurred,  is  to  pass 
a  small  five-sided  drill  until  it  fails  to  meet  with  resistance,  increasing 
by  a  larger  drill ;  and  from  these  two  half-circles  I  cut  in  either 
direction  with  suitable  chisels  by  carefully  splitting  down  the  ena- 
mel,— first  the  masticating  portion, — and  continuing  until  a  free 
space  is  secured  on  the  inner  side ;  then  more  carefully  opening 
toward  the  buccal  division,  until  a  slight  space  is  made  at  this 
point.  The  tile  may  be  used  at  this  stage  to  further  open  the  space, 
and  in  bringing  the  surfaces  into  proper  shape  and  smoothness. 
When  the  cavities  are  so  large  as  is  assumed  above,  there  will 
usually  be  found  so  much  disorganization  of  the  enamel  as  to  render 
necessary  so  much  cutting  to  procure  a  healthy  surface  as  will  open 
a  space  abundantly  large  for  the  subsequent  work.  If  more  is  needed, 
it  is  secured  by  wedging  ;  in  any  case  a  separation  as  large  at  the 
lower  part  as  a  No.  7  Froid  file,  and  at  the  cervical  part  as  a  No.  3, 
is  easily  secured.  The  buccal  space  should  be  but  slightly  wedge- 
shaped,  and  somewhat  smaller  than  the  palatal,  for  reasons  which 
will  appear  in  the  proper  place. 

"After  removing  the  softer  caries,  the  walls  of  the  cavity  are 
prepared  for  the  reception  of  the  filling;  the  overhanging  masti- 
cating plate  being  first  cut  away  in  a  circular  form  on  a  line  with 
the  bottom  or  pulp  wall,  so  that  by  direct  approach  every  part  of 
the  cavity  is  accessible  to  slightly  curved  or  even  straight  instru- 
ments. This  opens  the  whole  cavity  to  view.  The  instrument  best 
adapted  for  this  purpose  is  the  gouge-shaped  chisel,  which  cuts  with 
exceeding  keenness,  and  produces  the  form  desired  at  this  part. 
The  removal  of  this  portion  of  the  enamel  is  an  important  and  indis- 
pensable step  in  the  improvement  I  am  pursuing.  It  is  practiced 
by  the  better  operators  to  a  somewhat  less  degree,  and  is  in  many 
cases  an  advantage  to  the  organ.  No  other  argument  to  defend 
this  course  need  be  used  than  that  in  these  fillings,  so  difficult  of 
execution,  everything  subservient  to  better  performance  must  be  fol- 
lowed out  which  is  not  injurious  to  the  strength  and  preservation 
of  the  organ.  It  will  often  prove  true  here,  as  elsewhere  in  surgery, 
that  something  must  be  taken  to  save  the  remainder. 

"  The  cervical  wall  is  now  cut  at  a  right  angle  to  the  proximal  sur- 
face, taking  care  to  remove  from  the  surface  of  the  tooth  beneath 
the  gum  any  half-decomposed  enamel  which  may  be  present  at  this 
part.     No  retaining  groove  or  pits  are  needed  on  this  wall. 


330  ORAL  DISEASES  AND  SURGERY. 

"The  buccal  and  palatal  walls  are  next  smoothly  cut,  and  on  the 
side  of  each,  where  they  have  sufficient  strength,  a  shallow,  round- 
bottomed  groove  is  made  the  whole  length,  and  terminating  at  the 
very  surface  of  the  masticating  jdMc  of  enamel.  The  outer  retain- 
ing groove  should  be  near  the  margin,  to  avoid  any  approach  to  the 
pulp  ;  the  inner  one  should  be  nearer  the  bottom  of  the  cavity,  that, 
in  the  subsequent  cutting  away  of  a  portion  of  the  palatal  wall  in 
the  finishing  process,  the  hold  of  the  gold  may  not  be  obliterated. 
The  instruments  best  adapted  for  this  grooving  are  made  by  filing 
a  straight  point  quite  round  and  small,  then  bending  at  a  suitable 
angle,  and  shaping  so  as  to  have  the  edge  at  the  inner  side  of  the 
curve.  Instruments  of  this  form  are  better  adapted  for  cutting  the 
hard  dentine  and  enamel  than  any  others,  for  the  reasons  that  they 
may  be  made  harder  than  usual  without  danger  of  breakage;  they 
cut  with  more  keenness,  do  not  chatter,  leave  the  surface  without 
sharp  lines,  and  in  grooving  each  cut  follows  in  the  last  with  cer- 
tainty. They  are  directly  reverse  in  form  to  the  hoes  and  exca- 
vators in  general  use. 

"  The  pulp  wall  of  the  cavity  is  not  altered  in  the  form  it  presents 
after  the  removal  of  the  caries. 

"  The  next  and  very  important  step  is  to  remove  the  sharp  corners 
of  the  mouth  of  the.  cavity,  and  at  every  part  well  polish  it  with 
pumice-stone ;  this  facilitates  the  passage  of  the  gold  over  the  sur- 
face and  the  perfect  contact  of  the  foil  with  every  part.  This  polish- 
ing is  rapidly  done  by  rotating  a  piece  of  boxwood  armed  with 
pulverized  pumice. 

"  Selection  is  now  made  of  one  of  the  appliances  figured  below, 
which  are  intended  to  give  farm  to  the  outer  surface  of  the  filling, 
and  are  called  matrices  for  this  reason.  These  little  affairs  are  made 
of  a  variety  of  shapes,  sizes,  and  thicknesses.  They  are  formed  of 
slightly  wedge-shaped  pieces  of  steel,  and  are,  as  the  cut 
designates,  hollowed  out  at  their  thicker  edge,  which 
depression  terminates  at  the  thinner  edge.  At  the  part 
of  the  depression  designed  to  give  shape  to  the  buccal 
edge  of  the  filling  the  cut  is  generally  abrupt  and  deep;  at  the  inner 
portion  it  is  more  shallow  and  more  inclined.  It  will  be  observed 
that  the  depression  widens  as  it  passes  toward  the  thinner  edge  to 
follow  the  usual  form  of  proximal  cavities.*     The  lower  and  thin 

*  In  Fig.  104  tho  boundary  of  the  right  end  of  the  depression  should  be 
similar  to  the  other  end. 


LOCAL    TREATMENT   OF  DENTAL   CABLES.        331 

edge  is  rounded,  to  outline  the  curved  margin  of  the  cervical  wall, 
and  to  effect  pressure  upon  either  the  gum  or  the  appliances  used 
to  stop  the  escape  of  mucus  and  blood  from  this  tissue. 

"  The  plane  parts  of  the  face  are  file-cut  or  coarsely  draw-filed.  The 
reverse  side,  represented  at  Fig.  105,  and  which  for  convenience  of 
description  is  divided  into  three  sections,  is  in 
most  cases  plane  and  smooth,  excepting  at  tbe 

section  c,  which  is  file-cut.     It  is  often  necessary     " -<!F^'^'' — ^ 

to  have  this  side  in  two  surfaces;  onCj  section     c .^x^^—^^ 

a,  parallel  with  the  plane  parts  of  the  face,  and 
from  this  point  inclining  to  a  thin  edge.     A  very  desirable  form  is 
to  have  section  c  bent  backwards  to  follow  the  incline  of  the  proxi- 
mate tooth  beneath  the  gum.     At  each  end  a  square  cut  is  made  to 
fit  the  plier  ends  represented  at  Fig.   106.     After  being 
formed,  they  are  protected  from  oxidation,  heated  to  red- 
ness, plunged  in  the  cold  bath,  and  temper  drawn  to  near       &  %^ 
blueness  ;  after  polishing  the  depression,  they  will  be  ready  ) 

for  use.  Quite  a  number  of  pairs  are  necessary  to  meet 
the  requirements  of  the  differing  cases;  but  for  the  ordinary-sized 
simple  proximal  cavities,  a  dozen  pairs,  varying  in  width,  in  thick- 
ness, and  in  size  of  depression,  are  all  that  I  have  found  necessary. 
Fig.  104  represents  the  largest  size  required,  those  most  in  use  not  being 
more  than  from  one-half  to  two-thirds  this  width  and  thickness.  The 
character  of  these  modifications  will  depend  somewhat  upon  the  de- 
sired end,  since  either  a  flat,  contour,  or  excessively  convex  surface 
may  be  produced  at  the  pleasure  of  the  operator,  or  to  suit  the  needs 
of  the  individual  operation,  by  varying  the  form  and  depth  of  the 
depression.  It  is  also  occasionally  necessary  to  have  a  matrix  of 
unusual  form  to  meet  special  cases,  where  the  space  is  extremely 
great,  or  where,  from  the  fracture  of  the  outer  plate  of  enamel,  a  steel 
one  will  not  remain  in  position  ;  for  this  purpose  I  have  found  hard 
boxwood  to  answer  quite  well.  Silver  also,  in  such  cases,  will  occa- 
sionally be  found  useful.  I  sometimes  take  an  impression  of  the 
immediate  part  to  assist  me  in  the  fabrication  of  a  suitable  appli- 
ance. I  have  also  some  double-faced  ones,  which  are  so  formed  as 
on  one  adjustment  to  allow  both  cavities  to  be  filled.  For  isolated 
teeth  having  large  posterior  cavities,  a  ring  of  silver  may  be  used, 
carrying  out  the  same  principle  in  forming  the  portion  which  bounds 
the  cavity.     I  have  used  the  same  plan  in  buccal  cavities. 

"  The  selected  matrix  should,  at  the  convex  edge,  be  a  little  thinner 
than  the  space  between  the  teeth  at  their  closest  part  by  the  gum  ; 


832  ORAL  DISEASES  AND  SURGERY. 

it  should  pass  above  the  edge  of  the  cervical  wall,  and  should  con- 
form at  this  part  to  the  contour  of  the  tooth  ;  the  lower  and  thicker 
edge  should  reach  nearly  to  the  masticating  surface,  and  this  edge 
should  not  entirely  fill  the  lower  part  of  the  space ;  abo.ve  all,  the 
depression  at  every  part  of  its  bor^der  should  extend  slightly  beyond 
the  edge  of  the  cavity.    . 

"  After  having  secured  the  cervical  part  of  the  case  from  the  en- 
croachment of  moisture,  which  I  do  by  various  means, — viz.,  the 
wedge  of  wood,  little  rings  of  india-rubber,  the  string  dam,  short 
pieces  of  waxed  twine,  of  such  size  as  to  remain  firmly  in  place 
when  drawn  between  the  teeth,  the  application  of  dilute  chloride  of 
zinc,  etc.,  or  a  combination  of  two  or  more  of  these  means, ^the 
matrix  is  taken  up  in  the  pliers  (Fig.  lOfi),  and  pushed  upwards  until 
it  presses  upon  the  gum  or  the  appliances,  and  until  it  impinges 
tightly  between  the  teeth.  It  is  now  wedged  firmly  against  the 
tooth  to  be  operated  upon,  with  little  boxwood  wedges  ;  these  secure 
it  in  place  during  the  packing.  When  the  matrix  passes  up  to  the 
proper  point,  the  wedging  towards  the  cavity  throws  the  lower  edge 
against  and  somewhat  beneath  the  projecting  swell  of  enamel  of  the 
neighboring  tooth,  which  adds  to  the  security.  However  tightly 
the  matrix  may  fit  between  the  teeth,  it  will  not  frequently  retain 
its  fixedness  unless  securely  wedged.  Boxwood  answers  for  this 
purpose  better  than  any  substance  I  have  employed,  for  the  reason 
that  it  is  so  hard  as  to  be  unyielding,  and  on  this  account  also  does 
not  require  to  be  more  than  pushed  into  the  space.  The  wedges 
should  be  made  in  quantities  for  convenience  of  selection.  The 
pliers  (Fig.  106)  are  adapted  to  their  introduction. 

"  In  case  the  adjoining  teeth  are  not  in  contact,  it  is  always  neces- 
sary to  introduce  a  wedge  between  them,  to  give  greater  firmness 
to  the  teeth  and  less  discomfort  to  the  patient.  In  all  large  cavities 
I  fix  the  matrix  previous  to  introducing  the  napkins.  Where  the 
rubber-dam  is  required,  it  precedes  this  appliance,  which  may  aid  in 
keeping  the  rubber  in  place. 

"  For  the  small  cases,  the  drying  is  done  first,  the  napkins  applied, 
„      ^  and  a  hard  rope  of  bibulous  paper  is  passed  against 

the  gum,  followed  b3^the  matrix.  Fig.  101  represents 
the  appearance  of  the  parts  at  this  stage,  except  the 
wedges,  which  are  not  shown.  When  the  cavity  is 
now  examined,  it  will  be  found  to  present  an  open 
mouth,  formed  by  its  curved  lower  edge  of  enamel, 
and  by  the  boundary  of  the  matrix,  through  which   funnel-shaped 


LOCAL    TREATMENT   OF  DENTAL    CARIES.        33^ 

opening  every  part  of  the  space  is  easily  seen  and  directly  touched. 
The  case  is  now  ready  for  the  reception  of  gold. 

"  I  use  for  the  upper  half  or  more  of  the  filling,  ribbons  of  Nos.  4,  5, 
or  6,  of  slightly  adhesive  gold,  but  not  annealed.  These  ribbons  are 
made  of  one-fourth  to  whole  sheets  of  foil,  depending  on  the  size  of 
the  space,  and  then  folded  into  blocks,  varied  in  length  by  the 
requirements  of  the  case.  For  the  lower  third  I  prefer  rolled  gold 
of  No.  20  to  30,  of  the  most  adhfisive  character,  and  annealed.  I 
also  use  for  this  part  in  many  cases  'Eureka  gold  filling,'  No.  15, 
with  the  greatest  advantage,  taking  up  one  or  more  of  the  shreds, 
and  working  them  in  wherever  needed.  The  first  block  or  mat  is 
passed  up  toward  the  outer  border,  until  it  reaches  the  cervical  wall, 
when  the  lower  end  is  pushed  into  place,  and  fastened  by  pressure 
into  the  upper  part  of  the  retaining  groove.  The  second  piece  is 
secured  in  the  same  manner  in  the  inner  or  palatal  groove  ;  a  further 
piece  is  forced  between  the  two,  and  directly  against  the  cervical 
wall.  When  a  sufficiency  of  gold  is  placed  upon  these  parts  to  save 
the  tooth  from  contact  of  the  points,  the  gold  is  securely  malleted 
against  the  walls  at  all  points,  paying  particular  attention  to  the  junc- 
tion of  the  tooth  with  the  matrix.  In  this  way  I  proceed,  success- 
ively introducing  and  malleting,  until  the  cavity  is  two-thirds  filled, 
nor  hastening  further  at  any  point,  unless  the  assurance  is  reached 
that  the  gold  is  perfectly  consolidated.  At  this  point  I  commence 
and  continue  the  employment  of  heavy  gold,  the  first  pieces  of  which 
should  be  well  fixed  in  the  gold  previously  introduced  at  the  parts 
over  the  retaining  grooves,  and  also  worked  well  into  the  founda- 
tion. It  is  now  a  simple  matter  to  fill  up  the  remainder  with 
quickness. 

"  In  case  there  should  happen  to  be  an  encroachment  by  moisture 
at  or  near  the  close  of  the  packing,  the  gold  may  be  made  smooth  on 
the  exposed  surface,  dried,  and  the  latter  part  inserted,  with  all  the 
characteristics  of  a  separated  filling.  The  form  of  the  last  third  is 
such  that,  if  inserted  with  dryness,  no  portion  can  escape.  The 
matrix  should  now  be  removed. 

"It  will  be  found,  if  the  selection  and  adjustment  of  the  matrix  have 
been  correct,  that  very  little  filing  and  cutting  down  of  the  plug  will 
be  required,  and,  in  case  the  packing  has  been  carefully  performed, 
that  the  gold  will  be  solidly  condensed  at  every  part.  It  will  also 
be  noticed  that,  while  the  gold  is  solid,  it  will  not  have  become 
hardened  in  temper  on  the  proximal  surface,  but  yields  laterally 
under  the  burnisher,  not  unlike  lead  or  tin. 


334  ORAL  DISEASES  AND   SURGERY. 

"  I  must  at  this  time  call  attention  to  the  importance  of  the  adapta- 
tion of  the  filling  material  to  the  cervical  wall,  which  it  requires  no 
words  to  show  will  be  secured  by  this  method.  There  can  hardly 
be  a  question  that  the  general  failure  of  proximal  fillings  is  due  to 
one  or  both  of  two  causes, — the  imperfect  preparation  of  the  cavity, 
and  the  want  of  solidity  and  adaptation  of  the  gold  at  this  part. 
When  the  filling  extends  to  the  gum  or  beneath  it,  and  the  teeth  are 
not  permitted  to  come  into  apposition  here,  this  portion  of  the  tooth, 
when  well  protected,  is  least  liable  to  decay,  as  this  is  not  the  place 
where  caries  usually  commences.  And  when  the  filling  reaches  to 
the  cementum,  the  recurrence  of  caries  is  still  less  to  be  appre- 
hended, since  it  is  a  clearly  established,  but  apparently  overlooked, 
principle  that  this  structure  is  the  least  liable  of  the  dental  tissues 
to  destruction.  It  will  be  noticed  how  seldom  failures  occur  along 
the  cervical  edge  of  gutta-percha  fillings,  even  when  carelessly  per- 
formed. These  considerations  have  been  forcing  many  to  seek  for 
better  means  of  securing  adaptation,  solidity,  and  smoothness  at 
this  part. 

"  The  instruments  for  introducing  the  filling  are  of  simple  forms 
and  direct  action,  but  they  should  be  in  fine  condition, — that  is,  the 
points  should  be  well  serrated,  and  sharp.  The  only  im- 
portant modification  needed  are  some  pairs  of  mated  plug- 
gers,  formed  as  at  Fig.  108,  in  which  one  side  of  the  edge  is 
considerably  longer  than  the  other,  which  longer  side,  in 
malleting,  is  constantly  kept  against  the  matrix;  this  effects 
the  greatest  pressure  upon  the  margins,  and  secures  with 
positiveness  the  perfect  fullness  and  the  proper  consolida- 
tion of  the  gold  at  these  parts.  Several  sizes  and  varied 
curves  of  this  point  are  required. 

"  The  finishing  of  the  case  is  not  different  from  the  usual 
course  pursued.  In  my  own  practice  I  open  still  further  the  inner 
portion  of  the  space,  which  is.  easily  done  with  chisels  and  suitable 
files.  The  peculiar  form  of  the  depression  in  the  matrix  produces  a 
space  which  is  considerably  greater  on  the  inner  side,  and  which 
may  be  increased  at  pleasure.  In  many  cases,  where  the  tendency 
to  caries  is  very  great,  I  chisel  quite  freely  from  the  inner  plates 
of  enamel,  doing  this  after  both  the  adjoining  fillings  are  inserted, 
cutting  down  both  gold  and  enamel  together,  allowing  the  fillings  to 
touch  only  at  the  prominent  outer  part.  The  result  is  then  an  imita- 
tion of  the  exceedingly  oval  bicuspid ;  of  the  immunity  from  decay 
of  which  all  must  have  seen  examples. 


LOCAL    TREATMENT  OF  DENTAL    CARIES.        835 

"  Fig.  109  represents  a  transverse  section  of  two  cases  at  a  point 
immediately  above  the  grinding  surface,  which  ex- 
hibits the   outline  of  the   form  of    the   cavity  and  ^^' 
finished  surface  of  the  gold. 

"  In  full  confidence,  founded  on  sufficient  trial,  I 
claim  that  this  method  of  filling  proximal  cavities 
overcomes  several  of  the  chief  difficulties  and  de- 
ficiencies hitherto  experienced,  as  well  as  enables  greater  facility  of 
performance,  and  the  security  of  excellent  results. 

"  I  have  not  mentioned  a  number  of  secondary  advantages,  which 
I  must  leave  to  that  class  of  operators  who  alone  will  adopt  this 
plan,  and  who  are  of  such  capacity  as  to  seize  upon  all  the  favorable 
features  of  this  method,  and  who  will  make  the  indefinite  application 
and  improvements  of  which  it  is  susceptible. 

"  In  my  own  hands  it  has  enabled  me  to  execute  with  greater  ease 
and  with  more  certainty  the  large  distal  cases  than  I  was  previously 
capable  of  accomplishing,  under  favoring  circumstances,  in  fillings 
of  equal  size  on  the  mesial  surfaces." 

Referring  again  to  the  diagram,  Fig.  T8,  attention  may  be  directed 
to  the  filling  of  the  very  irregular  crown  cavities  represented,  two  of 
which  are  shown  running,  upon  the  first  molar,  into  the  lateral  walls. 
In  filling  such  cavities,  the  operation  is  to  be  accomplished  without 
much  difficulty  by  introducing  first  into  either  extremity  (which  has 
been  prepared  as  described)  cylinders  or  plates  of  gold,  and,  after 
securing  the  fixedness  of  these,  packing  subsequent  plates  or  twist- 
pellets  one  after  the  other,  until  the  line  of  association  is  full.  It  is, 
however,  in  instances  of  this  kind  that  the  use  of  the  adhesive  gold 
is  felt  to  be  almost  a  necessity.  Working  gold  so  prepared  and 
understood,  one  would  scarcely  be  likely  to  depend  on  the  mode 
just  described. 

A  last  study  that  may  seem  necessary  to  make  in  connection  with 
the  exclusive  use  of  the  non-adhesive  gold,  may  be  directed  to  the 
cavity  seen  in  the  crown  face  of  the  wisdom  tooth.  Fig.  78,  right 
side.  This  cavity  has  a  complex  relation  only,  however,  from  the 
fact  that  it  is  seen  to  be  half  covered  by  an  operculum  of  gum  tissue. 
In  filling  such  a  cavity  (or,  indeed,  rather  would  it  pertain  to  the 
preparation  of  the  cavity),  it  is  found  necessary  to  uncover  entirely 
the  parts:  to  accomplish  this,  tufts  of  cotton  or  sponge  may  be 
thrust  between  the  tooth  and  operculum,  which  tuft,  in  the  process 
of  swelling,  will  sometimes  remedy  the  trouble  by  thrusting  the 
gum  beyond  the  posterior  wall  of  the  tooth,  around  which  it  may 


336  OBAL  DISEASES  AND  ^URGERY. 

contract,  and  so  afterwards  be  held.  A  much  more  common  require- 
ment, however,  is  the  entire  removal  of  the  fleshy  lid  by  amputa- 
tion, the  part  being  lifted  upon  a  tenaculum  and  snipped  off  with 
scissors  or  bistoury.  The  operculum  removed,  the  cavity  is  at  once 
converted  into  the  most  simple  form. 

Adhesive  Foil. — Adhesive  foil,  as  implied  in  the  name,  is  sticky. 
Two  leaves  of  such  gold  pressed  together  with  a  very  moderate  de- 
gree of  force  will  adhere  with  such  tenacity  that  they  may  not  after- 
ward be  separated. 

To  fill  a  tooth  with  adhesive  foil,  an  absolute  dryness  is  essential 
to  success.  To  prepare  such  gold  for  use,  it  is  desirable  that  the 
operator  first  wash  his  fingers  with  alcohol :  this  cleans  and  dries 
them  thoroughly.  The  foil  is  now  to  be  prepared  according  to  the 
number,  used:  being  folded  loosely  into  twists  or  cut  into  strips. 
In  my  own  practice,  confining  myself  almost  exclusively  to  what  is 
known  as  No.  5, — that  is,  a  leaf  of  this  number  of  grains  in  weight, — 
it  is  my  habit  first  to  fold  the  full  leaf  ribbon-fashion,  making  the 
folds  very  loose,  and  about  an  inch  in  breadth  ;  afterward  lightly 
twist  it  upon  itself  In  making  the  twist,  it  seems  to  my  own  expe- 
rience that  nothing  is  more  necessary  than  that  the  bright  polish  of 
the  foil  should  not  be  broken,  while  to  avoid  so  breaking  it  requires 
only  the  exercise  of  a  very  little  care.  The  twists  are  to  be  cut  into 
pellets. 

Heavier  foils — those  which  range  from  20  to  120 — are  commonly 
used,  cut  into  little  oblong  squares, — a  delicate  strip  being  first  cut 
from  the  leaf,  and  this  subdivided  into  pieces  of  a  size  suited  to  the 
cavity  to  be  filled.  These  heavy  numbers  are,  however,  confined 
mostly  to  use  on  the  surface  of  a  filling  the  bulk  of  which  has  been 
made  by  the  lighter  foils,  or  are  otherwise  employed  for  filling  the 
root  canals, — which  see. 

Adhesive  foil  exposed  to  the  atmosphere  loses  always  more  or 
less  of  its  quality,  this  being  a  result  of  surface-moisture  and  dust- 
To  restore  the  adhesiveness,  it  is  the  practice  to  anneal  it,  doing  this 
either  by  laying  it  upon  a  heated  plate,  or  by  passing  it  through 
the  flame  of  a  spirit-lamp.  The  amount  of  heat  to  which  foil  is 
to  be  subjected  will  be  found  to  vary  considerably.  A  satis- 
factory test  is  found  in  the  touch.  My  own  plan  is  to  pass  the 
twist  through  the  flame,  and  then  touch  to  it  a  finger:  if  it  sticks,  it 
is  to  be  considered  sufficiently  annealed  ;  if  it  does  not  stick,  greater 
heat  is  required.     A  practice  with  many  is  to  heat  every  twist  to  a 


LOCAL    TREATMENT  OF  DENTAL    CARIES.        337 

clierry-red  ;  and  while  such  a  rule  ma}'  be  found  generally  appli- 
cable, many  lots  of  foil  will  be  met  with  to  which  the  treatment 
would  be  ruinous.  A  rule,  however,  to  be  observed  in  every  case  is 
not  to  burn  the  gold  or  heat  it  to  an  extent  which  destroys  its  soft- 
ness. A  foil  that  is  not  made  adhesive  by  a  heat  which  varies  from 
that  which  shall  simply  dry  it  up  to  that  which  exhibits  the  red,  can 
never  be  made  so  by  any  such  means ;  it  is  faulty. 

It  is  not,  however,  to  be  understood  that  adhesive  foil  always 
requires,  annealing  at  the  hands  of  the  operator.  Many  makes  are 
so  perfect  in  this  respect  as  received  from  the  manufacturers,  that  it 
is  only  necessary  to  keep  the  books  in  a  strictly  dry  place,  and 
inclosed,  when  not  being  used,  in  the  envelopes  which  accompany 
them. 

Placing  foil  in  the  rays  of  the  sun,  transmitted  through  glass,  as 
an  ordinary  window,  is  one  of  the  most  satisfactory  ways  of  anneal- 
ing. In  cool  weather  I  seldom  employ  artificial  heat,  finding  the 
sunshine  to  answer  every  purpose. 

The  instruments  with  which  adhesive  gold  is  worked  are,  as  be- 
fore mentioned,  serrated.  In  the  production  of  such  instruments, 
the  most  accomplished  skill  has  exerted  itself,  both  in  the  way  of 
devising  forms  and  in  manufacturing.  Instruments  when  too  deeply 
serrated  cut  the  gold,  when  too  smooth  they  fail  to  assist  the  natural 
adhesiveness  by  addition  of  the  quality  of  interdigitation.  Atten- 
tion, however,  is  to  be  directed  to  the  fact  that  operators  of  repute 
deny  the  necessity  for  serrations,  and  even,  indeed,  the  desirability  of 
using  instruments  so  prepared,  believing  that  adhesive  foil  is  to  be 
worked  with  better  results  by  smooth-faced  pluggers. 

To  afford  the  reader  all  advantage  which  may  be  gained  without 
actual  manipulative  trial,  cuts  are  inserted  representing  the  instru- 
ments of  serrated  character  most  in  esteem  by  the  experienced 
dentists  of  the  country.  It  is  to  be  found,  perhaps,  that  in  the  use 
of  these,  as  with  the  use  of  the  various  numbers  of  foil,  familiarity 
constitutes  the  best  recommendation. 

Fig.  110  exhibits  perfectly  the  features  of  a  set  of  pluggers,  com- 
prising fifty-nine  instruments,  designed  by  William  H.  Atkinson, 
M.D.,  of  New  York  City,  and  known  by  his  name.  Although 
intended  to  be  used  with  the  mallet, — a  process  yet  to  be  described, 
— these  instruments  are  found  adapted  to  hand  -  pressure  also. 
Lately,  however,  this  set,  long  among  the  most  celebrated,  has 
been  renounced  by  the  designer,  in  a  preference  for  smooth-faced 
pluggers.     Much  reputation   still    attaches  to  them  with  the  best 

22 


338 


ORAL  DISEASES  AND  SURGERY. 


practitioners.     A  too  great  depth  in  the  serrations  is  an  ob- 
jection that  has  been    urged.     A  set  of   these    instruments, 

Fig.   110.— The  Atkinson  Pluqgers. 


o  n    n    n   n  ■'     * 


n     n 


2  3   4   5   6   7   8   9   10   11  12   13  14  15  16   17  18  19   20   21 


38  49   50   51   52   53    54   55  56   57    58     59 


LOCAL    TREATMENT  OF  DENTAL    CARIES. 


339 


Fig.  111. — Burnishers. 


r^ 


consisting  of  twenty-four  pieces,  selected  from  the  full  coai- 
plement,  is  found  to  answer  the  purposes  of  most  operators. 
Accompanying  these  pluggers  is  a  set  of  burnishers  of  designs 
corresponding  with  requirements.  Fig.  Ill  exhibits  these  bur- 
nishers. 

A  set  of  pluggers,  composed  of  sixteen  pieces,  designed  by 
C.  R.  Butler,  M.D.,  is  represented  in  Fig.  112.  These  are  in 
great  favor  with  a  wide  circle  of  operators.  The  serrations, 
as  seen  in  the  cuts,  are  very  fine. 

Fig.  112. — The  Butler  Pattern. 

•    0    a    i    8    0   a   © 


2  3         4        5  6        7  8  9        10        11       12        13       l-l       15       lb 


340 


ORAL  DISEASES  AND  SURGERY 

Fig  113. — The  Varney  Pattern. 


YY  / 


Still  another  set  having  individuality  and  reputa- 
tion is  known  as  the  Varney  pluggers,  being  the  design 
of  an  operator  of  experience  and  i*ecognized  position. 
The  serrations  of  these,  like  those  of  the  Butler  instru- 
ments, are  very  fine  and  very  close.  The  set  com- 
prises thirteen  pieces.  Fig.  113  represents  these  instru- 
ments. 

Another  set,  and  which  is  the  last  that  space  will 
permit  to  be  represented,  is  shown  in  Fig.  114.  These 
are  known  as  the  Abbott  pattern.  Like  the  others,  they 
have  many  admirers.  The  forms  of  these  instruments 
will  certainly  not  soon  be  surpassed.  It  would  scarcely 
seem  possible  that  an  indication  could  present  in  shape 
or  situation  of  a  cavity  that  some  one  or  other  of  these 
points  would  not  reach. 

Other  pluggers,  well  known  and  widely  used,  are 
sets  known  as  Jack's,  Ellis's,  Goodwillie's,  Forbes's, 
Darby's,  and  Head's.  It  is  well,  when  visiting  dental 
depots,  to  examine  the  many  pronounced  improvements 
constantly  being  issued,  and  to  purchase  accordingly. 

A  set  of  instruments,  which  experience  is  thought  to 
demonstrate  as  being  full  and  complete  for  the  purposes 
of  filling  teeth,  is  made  up  of  the  following  pieces. 
These  constitute  a  case  recommended  to  the  class  of  the 
Philadelphia  Dental  College  by  the  Professor  of  Opera- 
tive Dentistry  in  that  institution. 


LOCAL    TREATMENT   OF  DENTAL    CARIES.        311 


Fig.  114. — The  Abbott  Pattern. 


12       3        4      5  6       7         8       9        10         11      12       13       14       16       16     17        18 


U  I  ;  T 


•        7  • 


25      26      27       28      29       30 

Operating  Case. 


31      32        33      34     35 


7  Head's  excavators,  4,  7,  12,  17,  18,  20,  21. 

1  Palmer's  nerve  instruments,  each  Nos.  2  and  3. 
1         "  "  "  No.  5. 

1  "  "  "  No.  15. 
4  auger  drills,  two  No.  3,  8,  and  6. 

2  retalning-point  drills,  Nos.  1  and  2. 

8  wheel  burs,  Nos.  1,  3,  5,  7,  12,  15,  18,  9. 
7  round  burs,  Nos.  1,  2,  3,  4,  7,  9,  12. 

1  cone  head,  odd  No.  6. 

1  Goodwillie's  excavator.  No.  32. 

2j\  dozen   standard   excavator   hatchets,  Nos.  16,  15,  14,  12,  10,  9,  50,  49, 

47,  99,  81,  82,  85,  86. 
2y\  dozen  standard   excavator   hoes,  Nos.  27,  28,  91,  75,  78,  79,  80,  57,  58, 

59,  60. 
2y5j  dozen  standard  excavator  scoops,  Nos.  65,  66,  67,  68. 
7  i-inch  f.  c.  pluggers  N.  Y.,  Nos.  127,  128,  101,  1,  4,  9,  99. 


342  ORAL  DISEASES  AND  SURGERY. 

\  dozen  S.  S.  W.'s  small  scalers,  Nos.  1  and  8. 

5  i-mch  f.  c.  burnishers,  S.  S.  W.'s,  8.  6,  2  ;  Darby's,  31  and  32. 

4  1-inch  f.  c.  pluggers ;  Ellis's,  10,  11,  12,  and  Darby's,  No.  8. 

1  universal  porte  polisher. 

1  box  corundum  points. 

1  long  handle  wood  magnifying  mouth-mirror. 

1  Cogswell  rubber-dam  holder. 

1  |-inch  f.  c.  rubber-dam  punch. 

1  glass  syringe,  silver-plated  mountings,  with  one  curved  pipe. 

1  J-inch  f.  c.  plugger,  bayonet-shape,  no  number. 

2  J-inch  f.  c.  scalers,  R.  L.  Stellwagen's  pattern. 
1  f-inch  bayonet-shape  condenser. 

1  octagon  handle  plain  steel  small  scaler,  No.  5. 

1  set  of  six  Jack's  chisels,  single-bladed,  heavy  handle. 

1  lead  mallet  in  gas-pipe,  nickel-plated. 

|-  dozen  five-sided  drills,  three-faced. 

1  set  of  ten  mallet-pluggers.     Nos.  1,  3,  4,  5,  6,  7,  8,  9  of  the  set  of  mallet- 

pluggers  for  sponge  gold.  No.  2  of  Ellis's  pluggers,  and  Atkinson's  . 

No.  32. 
\  dozen  Froid's  separating  files,  Nos.  00  and  8,  cut  three  sides. 
8  Murphy's  files,  Nos.  12,  20,  14,  33,  40,  41,  42,  19. 

3  "  "      Nos.  54,  99,  100. 

2  "  "      No.  81,  E.  and  L. 

2  Scotch  stones. 

1  box  each  pumice  and  polishing  putty. 

\  dozen  square  handle  probes,  one  foil-carrier  and  plugger  combined. 

1  abscess  lancet. 

1  student's  large  morocco  case. 

3  trays  and  instruments  fitted. 

Fillings  of  adhesive  gold  are  made  either  by  hand-pressure  or  by 
the  use  of  a  mallet.  Where  the  latter  means  is  employed,  experi- 
ence certainly  demonstrates  the  necessity  for  shallower  serrations  in 
the  instruments.  Mallet  filling  consists  simply  in  condensing  the 
gold  by  repeated  taps  from  a  hammer  made  of  wood,  lead,  tin,  or 
steel,  applied  to  the  head  of  the  plugger.  To  employ  the  mallet,  an 
assistant  is  commonly  deemed  necessary,  although  not  by  any  means 
an  indispensable  adjunct,  the  operator  being  quite  able  to  manipu- 
late both  plugger  and  mallet.  Fig.  115  represents  the  size  of  mallets 
ordinarily  used.  No.  1  is  made  of  metal, — lead,  preferably ;  No.  2 
is  made  of  lignum-vitse. 

Provided  with  some  selection  of  the  serrated  pluggers,  the  opera- 
tion of  fixing  and  packing  adhesive  gold  may  very  well  be  practiced 
to  its  appreciation  by  employing  the  perfectly  clean  surface  of  a  metal 
dollar,  either  silver  or  gold  being  used,  as  may  be  most  convenient. 


LOCAL    TREATMENT  OF  DENTAL   C ABIES. 


343 


First,  that  a  hold  may  be  secured,  the  operator  makes  a  series  of 
cross-scratches  over  any  portion  of  the  surface.  Taking  up  now 
with  the  serrated  point  a  pellet  of  gold  which  has  been  prepared,  it 

Tig.  115. — Plugging  Mallets. 


is  laid  upon  the  scratches,  and  by  a  very  few  manipulative  touches  is 
solidly  attached  to  the  coin.  The  building  up  of  a  cone  to  any  de- 
sired height  is  simply  a  repetition  of  these  attachments.  Appre- 
ciating thus  the  principle  upon  which  a  plug  of  adhesive  gold  is  to 
be  constructed,  the  practice  may  now  be  extended  to  simple  crown 
cavities  in  teeth. 

To  fill  a  simple  crown  cavity  with  adhesive  gold,  the  operator 
(after  the  adoption  of  such  means  as  shall  insure  him  to  the  end  of 
the  operation  against  the  inroad  of  saliva)  takes  up  a  piece  of  metal 
of  such  size  as  being  packed  solidly  in  the  bottom  of  the  cavity  shall 
give  it  fixedness ;  upon  this  first,  piece  after  piece  is  to  be  at- 
tached, precisely  as  in  the  case  of  the  coin.  If  the  mallet  is  used, 
each  second  or  third  layer  is  to  be  condensed  with  it,  although  it  is 
a  habit  with  many  operators  to  mallet  every  pellet ;  a  plan  only 
permissible  where  the  shallowest  serrations  are  used,  such  frequent 
blows,  where  the  instruments  are  at  all  deeply  cut,  quickly  destroy- 
ing the  integrity  of  the  plug,  as  may  very  well  be  understood. 

Another  mode  of  fixing  the  first  piece  of  foil  in  such  a  cavity  is 
to  make  at  some  convenient  spot  what  is  called  a  retaining  point : 


344  ORAL   DISEASES  AND   SVRGERV. 

this  is  simply  a  sliglit  undercut  or  slot:  this  first  piece  being  worked 
into  this  slot,  the  remainder  of  the  filling  is  attached  to  it. 

A  much  more  convenient  and  certainly  more  expeditious  way  of 
filling  such  a  cavity  is  found  in  wedging  into  it  the  gold  prepared 
as  cylinders,  plates,  or  the  cut  rope.  When  no  more  can  possibly 
be  thus  introduced,  it  may  be  hand-worked  or  malleted  into  solidity; 
foil,  worked  after  the  adhesive  manner,  being  now  attached  wherever 
a  place  can  be  made  for  it :  thus  building  up  the  required  face. 

As  another  study  in  the  use  of  adhesive  foil,  reference  may  be 
had  to  the  cavities  seen  upon  the  grinding  faces  of  molar  teeth,  Fig. 
78,  running  over  into  the  lateral  surface.  With  the  cavity  prepared 
as  described,  the  operator  will  commence  by  fixing  in  either  ex- 
tremity a  pellet  of  gold,  this  being  solidly  malleted  into  place; 
upon  this,  pellet  after  pellet  is  attached,  until  the  irregular,  sulcus- 
like  place  is  filled. 

We  pass  now  to  the  proximal  cavities — exhibited  in  the  same 
figure — in  the  anterior  teeth.  Taking,  as  an  example,  the  incisor 
tooth:  the  operation  may  be  commenced  with  a  pellet  of  gold 
carefully  and  delicately  worked  into  an  undercut,  the  remainder  of 
the  plug,  as  before  directed,  being  attached  to  this.  A  plan,  how- 
ever, which  is  exceedingly  easy  and  convenient  consists  in  first  laying 
a  plate,  precisely  as  suggested  in  the  use  of  unadhesive  foil,  against 
the  neck- wall  of  the  cavity  ;  this  is  to  be  of  such  size  that  when 
consolidated  into  place  its  relation  with  the  boundaries  of  the  cavity 
makes  it  self-supporting.  Against  and  into  this  wall  of  gold  the 
adhesive  pellets  are  to  be  worked  with  such  serrated  instruments  as 
are  found  most  convenient  to  apply.  A  third  plan  of  filling  such 
cavities  consists  in  rolling  into  balls  three  suitable-sized  twists  of 
adhesive  foil.  Taking  up  the  first  ball,  it  is  carried  to  the  neck-wall 
and  there  partially  condensed.  The  second  ball  is  now  placed  in 
that  part  of  the  cavity  which  adjoins  the  cutting  edge;  the  third  ball 
is  wedged  between  the  first  and  the  second,  and  the  mass  is  now 
condensed  by  the  serrated  pluggers  against  the  labial  wall.  Having 
thus  a  support  of  gold  immovably  fixed  by  its  relations  with  the 
neck  and  base  of  the  cavity,  the  pellets  are  taken  up  piece  by  piece 
and  worked  into  it  until  .the  cavity  is  full. 

Still  another  plan,  practiced,  after  a  little  experience,  with  all  satis- 
faction, consists  in  taking  a  single  ball,  prepai-ed  as  just  described, 
and,  after  carrying  it  into  place  against  the  neck-wall,  holding  it  in 
position  by  means  of  any  convenient  instrument  until  it  is  condensed 
and  a  sufficient  addition  is  made  to  render  the  mass  self-supporting. 


LOCAL    TREATMENT  OF  DENTAL    CARIES.        345 

Yet  another  plan  is  found  in  the  employment  of  a  matrix.  This 
may  be  extemporized  out  of  almost  anything.  A  very  simple  mode 
consists  in  casting  first  a  ligature  of  heavy  silk  well  waxed  about 
the  neck  of  the  tooth.  Between  the  teeth — being  of  a  width  which 
shall  cover  in  about  one-fourth  of  the  neck  aspect  of  the  cavity — a 
piece  of  soft  silver  is  now  thrust  and  wedged  into  place  by  a  slip  of 
soft  wood.  Into  the  cavity  thus  formed  the  initial  of  the  plug  is 
placed.  A  temporary  matrix  of  this  nature  is  also  provided,  as  has 
been  before  suggested,  by  the  introduction  between  the  teeth  of  a 
lath-shaped  instrument,  the  initial  gold  being  by  such  means  sup- 
ported until  condensed  and  fixed. 

Heavy  foils,  even  as  high  as  Xo.  120,  are  used  by  some  operators 
in  filling  the  front  teeth  :  it  being  claimed  for  gold  so  prepared  that 
from  being  rolled  instead  of  beaten  it  is  rendered  softer  and  more 
adhesive.  Such  gold,  after  being  cut  into  delicate  strips,  is  attached 
across  the  surface  of  the  cavity,  retaining  points  being  first  prepared 
and  filled. 

Cavities  in  the  bicuspid  teeth,  proximal  surfaces,  are  filled  accord- 
ing as  they  may  have  been  prepared.  Where  the  Y-cut  has  thrown 
the  cavity  into  an  upward  outlook, — that  is,  has  given  it  more 
or  less  the  aspect  of  a  common  crown  cavity, — no  special  sug- 
gestions are  required  to  be  added  to  directions  already  understood. 
In  the  contour-fillings,  however,  each  case  will  possess  its  own 
peculiar  indications.  In  preparing  a  bicuspid  tooth  for  such  a  con- 
tour-filling it  will  be  remembered  that  the  cavity  is  cut  from  the 
grinding  face :  the  tooth  being,  as  it  were,  scooped  out.  This 
necessarily  makes  an  open,  free  cavity,  which  will  require  some  special 
means  of  support  for  the  first  piece  of  gold  introduced.  To  obtain 
this  support,  it  will  be  found  convenient  to  take  advantage  of  the 
undercut,  such  point  of  fixedness  being  secured  at  any  convenient 
spot  about  the  base  of  the  cavity.  A  first  piece  being  by  this  means 
fixed,  the  remainder  of  the  plug  is  built  upon  it,  the  gold  in  mass 
becoming  finally  self-supporting  as  the  cavity  is  packed.  The  use 
of  a  matrix  is  here  found  most  conducive  to  convenience  and  suc- 
cess. 

A  second  means  of  filling  such  cavities,  and  one  which  will  be 
found  easier  of  accomplishment  by  the  inexperienced,  consists  in  pre- 
paring a  series  of  plates  or  mats.  After  making  a  slight  retaining 
undercut  around  the  parietes  of  the  cavity,  a  first  plate  is  laid 
against  the  neck  surface  of  the  cavity  and  loosely  condensed  into 
place.     A  second  and  third  are  next  placed  against  the  lateral  walls, 


346  ORAL  DISEASES  AND   SURGERY. 

these  also  being  loosely  pressed  into  the  undercuts.  A  fourth,  fifth, 
and  sixth,  as  required,  are  now  wedged  into  the  centre,  each  wedge, 
as  will  be  seen,  tending  more  and  more  to  consolidate  and  fix  the 
first  layers.  Securing  thus  fixedness  for  the  gold,  the  whole  may 
be  carefully  hand-worked  or  nialleted  solidly  against  the  bottom  ; 
the  upper  part  of  the  cavity  (exposed  by  the  condensation)  is  filled 
by  working  adhesive  pellets  into  the  anchored  portion  of  the  plug, 
precisely  as  is  built  up  the  filling  first  described. 

In  filling  the  lower  teeth,  it  is  common  for  the  operator  to  be 
behind  his  patient,  standing  at  such  elevation  as  shall  enable  him  to 
lean  over  the  head  or  shoulder.  Such  a  position  is  found  to  add 
immensely  to  convenience  in  manipulating.  Another  posture,  prac- 
ticed by  many,  is  to  stand  at  the  side,  precisely  as  in  operating  upon 
the  upper  teeth, — a  position  that  is  found  to  answer  a  very  good 
purpose  where  the  cavities  to  be  operated  upon  occupy  the  buccal 
face  of  the  teeth,  but  which  certainly  cannot  be  compared  for  con- 
venience to  the  first  position  for  crown  or  proximal  cavities.  In 
manipulating  upon  a  cavity  in  any  part  of  the  mouth,  advantage  is 
of  course  to  be  taken  of  the  various  movements  permitted  by  the 
operating-chair  or  head-rest. 

Building  up  with  gold  the  entire  lost  crown  of  a  tooth  is  an  opera- 
tion frequently  practiced  by  expert  workers  with  adhesive  gold. 
Such  operations,  however,  are  too  often  to  be  viewed  rather  as 
exhibitions  of  nice  smithery  than  as  proper  and  judicious  surgical  per- 
formances, it  being  exceptional  that  the  root  built  upon  does  not 
rebel  against  the  treatment  pursued.  To  practice  operations  of  such 
a  class,  the  gold  receives  its  fixedness  either  by  anchorage  in  the 
pulp  canal,  or  by  gold  screws  roughened  to  attach  and  hold  the 
metal  worked  into  and  about  them.  A  plan  that  may  be  adopted, 
is  to  ream  out  the  root  precisel}^  as  for  the  accommodation  of  the 
tube  of  gold  so  frequently  employed  for  the  reception  of  artificial 
crowns,  as  in  the  process  of  pivoting.  (See  Pivot  Teeth.)  Into  the 
canal,  so  prepared,  is  inserted  the  screw,  which,  it  will  be  under- 
stood, has  close  relation  with  it  near  the  apex  only.  The  screw  is 
now  built  solidly  into  the  canal,  furnishing  a  support  for  the  crown, 
which  the  operator  builds  upon  and  about  it. 

In  the  case  of  molar  teeth,  the  practice  has  been  pursued  of  drill- 
ing several  holes  into  the  circumfei'ence  of  the  surface  to  be  built 
upon,  making  these  act  the  part  of  slots  for  the  fixing  of  bases  of 
gold,  or  the  introduction  of  supporting  screws.     Mack's  retaining- 


LOCAL    TREATMENT  OF  DENTAL   CARIES.        347 

screws,  together  with  the  instruments  designed  for  their  insertion, 
will  be  found  highly  self-commending  in  this  direction.  These  screws, 
made  of  gold,  are  of  delicate  workmanship,  and  may  be  fixed  into  a 
tooth  at  any  point,  with  entire  facility,  by  the  use  of  the  drills  and 
slotted  carriers,  which  accompany. 

Concerning  contour-fillings,  the  fact  is  not  to  be  overlooked  that 
such  manner  of  restoring  the  lost  parts  of  teeth  is  commended  by 

Fig.  116. — Automatic  Plugger. 


most  expert  and  experienced  operators.  And  in  this  volume  it  is 
only  meant  to  qualify  an  indorsement,  as  the  manipulations  are  so 
frequently  practiced  by  those  who  seem  to  consider  only  the  me- 
chanical aspect  of  their  cases.    Objections  to  grinding  surface  gained 


348 


ORAL  DISEASES  AND   SURGERY. 


could  certainly  apply  only  where  ill — necessarily  accruing  from  the 
particular  mode  of  operating- — counterbalanced  the  good. 

The  working  of  the  sponge  form  of  gold  and  of  the  prepared  foil- 
block  is  conducted  on  the  same  principle  and  with  the  same  form 
of  instruments  as  employed  with  the  adhesive  foil. 

Apparatuses  for  use  in  filling  teeth,  designed  for  the  saving  of 
time,  labor,  and  fatigue,  are  from  time  to  time  introduced  to  the 
notice  of  the  busy  operator.  Automatic  pluggers,  as  they  are 
termed,  are  highly  esteemed  by  many.  Fig.  116  represents  a 
form  of  such  instrument,  together  with  the  mode  of  handling  it. 
Of  agents  of  this  character,  several  modifications  are  found  in  the 
market,  and,  as  each  seems  possessed  of  some  special  virtue,  the 
mean  of  diff'erence  is  perhaps  not  very  great.  The  name  automatic 
mallet  seems  quite  as  appropriate  for  these  instruments,  as  the 
object  is  the  combination  of  the  mallet-blow  with  the  plugger.  The 
blow  is  the  result  of  ingeniously  arranged  spring-work,  and  may  be 
repeated  with  as  much  frequency  as  the  fingers  of  the  operator  can 
with  convenience  manipulate.  Directions  for  the  working  of  these 
various  machines  are  found  to  accompany  the  cases  in  which  they 
are  furnished. 

An  instrument  known  as  Bon  will's  electro-magnetic  mallet  is  ex- 


FiG.  117. — Electro-Magnetic  Mallet  (Half  Size). 


hibited  in  Fig.  IIT.     This  is  a  most  ingenious  piece  of  mechanism, 
and  in  the  hands  of  the  inventor  is  remarked  to  work  with  a  certainty 


LOCAL    TREATMENT   OF  DENTAL    CARIES.       349 

and  accuracy  which  would  seem  to  be  its  all-sufiScient  recommenda- 
tiou.  It  is  composed,  as  is  seen  by  refei'ring  to  the  diagram,  of  a 
horse-shoe  magnet  (H)  with  a  frame  attached,  which  supports  the 
mallet  or  armature,  and  at  the  opposite  end  the  cylinder  or  tube,  open 
on  one  side  for  the  thumb  to  rest  on  the  plugger,  which  passes  through 
it.  J,  the  spring  which  secures  the  plugger  from  passing  too  far 
either  way  in  the  tube.  0,  the  black  rubber  key  which,  when  pressed 
up  by  the  right  thumb  while  holding  the  instrument  in  hand,  forces 
the  lever  up  and  breaks  the  circuit  permanently.  C,  the  platina  points 
where  the  current  is  broken  at  the  binding-post  (P),  and  on  the  lever 
pressing  thereon,  which  is  controlled  by  the  slide  upon  which  rests  the 
right  index-finger.  This  is  for  the  temporary  breaking  of  the  current. 
P,  binding-posts  for  flexible  wires,  one  coming  from  the  battery  (N), 
and  the  other  from  clock-work  (M).  S,  screw  for  adjusting  the 
hard-rubber  head  which  strikes  upon  the  head  of  the  plugger.  S', 
screws  for  holding  the  points  or  pinions  which  attach  the  armature 
or  mallet  to  the  frame.  S",  screws  with  hard-rubber  heads,  to 
keep  the  armature  from  coming  in  direct  contact  with  the  iron  core 
of  the  helix  or  magnet,  and  which  are  adjustable  to  a  hair's  breadth. 
A,  the  conical  spring  which  sustains  the  mallet  and  causes  it  to 
be  thrown  back  from  the  helix  or  magnet.  It  is  adjusted  by  the 
screw  (I),  upon  which  it  rests,  with  binding  screw  for  same.  B, 
the  bobbin  or  automatic  feeder,  upon  which  can  be  rolled  a  yard  of 
gold  tape,  the  ends  being  held  together  by  pressure  of  hand  plugger. 
By  this,  the  operation  can  be  carried  on  continuously  where  free 
action  can  be  had.  T  is  a  deflector  for  directing  the  point  of  a 
curved  plugger  for  posterior  cavities  in  the  second  molars,  which  is 
screwed  fast  to  the  same  spot  where  the  automatic  feeder  now  rests, 
first  taking  it  off. 

The  most  important  point  to  be  kept  in  mind  about  this  mallet  is 
to  see  that  the  screws  (S")  are  just  far  enough  through  the  armature 
to  keep  it  from  coming  in  direct  contact,  at  any  part  of  the  surface 
of  the  mallet,  with  the  iron  cores  running  through  the  magnets,  and 
still  not  so  far  through  as  to  raise  the  mallet  beyond  a  very  trifle 
from  the  cores.     As  nearly  as  can  come  without  touching. 

This  is  necessary  for  two  reasons:  First,  if  allowed  to  touch  the 
cores  of  the  magnets,  the  latter  would  become  permanently  magnet- 
ized, and  would  not  let  the  mallet  fly  back  for  its  stroke;  second, 
by  thus  fineh'  adjusting  the  mallet  the  greatest  power  is  obtained, 
as  the  magnet  becomes  stronger  and  the  mallet  gains  in  rapidity 
and  sharpness  of  stroke  in  exact  ratio  as  it  approaches  the  magnet, 


360  OBAL  DISEASES  AND   SURGERY. 

and  inversely  becomes  weaker  as  it  I'ecedes.  Hence  the  screws  (S'') 
must  be  so  finely  set  as  to  prevent  any  contact  of  the  mallet  with 
the  cores.  The  same  may  be  said  of  S.  It  must  be  set  to  allow 
the  hard-rubber  head  to  move  the  plugger-point  about  the  one-fiftieth 
of  an  inch.  If  adjusted  to  strike  when  one-eighth  of  an  inch  away 
from  the  magnet,  it  would  lose  the  best — sharpest  and  strongest — 
part  of  the  blow.  Besides,  the  shorter  distance  the  plugger  travels, 
the  less  rebound  to  the  body  of  the  instrument  and  the  greater  gain 
to  the  patient  in  comfort,  as  well  as  solidifying  the  gold  far  more 
surely.  In  these  screws  lies  the  whole  secret  of  success,  according 
to  the  statement  of  the  inventor. 

The  screws  (S')  must  be  just  tight  enough  not  to  bind  the  pinions 
of  the  mallet,  and  a  drop  of  oil  placed  on  the  pinions  only,  occasion- 
ally, the  only  part  about  the  whole  instrument  which  must  be  oiled. 
The  screw  (I)  which  regulates  the  conical  spring  (A)  supporting  the 
mallet,  is  made  adjustable  with  the  binding  nut,  so  that  when  filling 
the  upper  teeth,  the  weight  of  the  mallet  is  enough  to  take  it  away 
from  the  magnet;  but  when  filling  the  lower  teeth,  the  spring  (A) 
must  be  made  strong  enough  to  throw  the  mallet  up  against  the 
screw  above,  regulating  the  distance  or  width  of  stroke. 

Where  a  heavy  stroke  is  wanted  in  regular  succession  for  some 
time,  let  the  mallet  have  longer  play;  if  soft  blows,  then  diminish 
the  distance.  Where  the  distance  is  great,  the  armature  cannot  fly 
back  and  forth  so  rapidly ;  only  where  the  distance  between  two  points 
is  less  will  the  mallet  run  the  faster.  Take  a  pendulum  for  illus- 
tration. The  mallet  should  run  fast  enough  to  strike  three  blows 
while  the  plugger-point  rests  at  each  touch  upon  the  gold. 

To  prevent  any  undue  waste  of  material,  the  hard-rubber  key  (0), 
which  is  controlled  by  the  right  thumb,  should  be  pressed  down, 
when  there  is  occasion  to  work  at  hand  pressure  or  something  else. 
This  breaks  the  circuit  at  the  post  (P),  and  when  no  circuit  there  is 
no  exhaustion  of  battery.  The  same  key  (0)  is  automatically 
pushed  back  again,  when  the  instrument  is  taken  into  the  hand  for 
use,  as  soon  as  the  second  joint  of  the  right  index-finger  comes  in  con- 
tact with  the  opposite  end  of  the  key.  The  slide,  upon  which  the  right 
index-finger  rests,  breaks  the  current  temporarily,  by  drawing  it 
backward,  allowing  no  stroke  of  the  mallet  at  the  time,  and  enabling 
the  operator  to  take  up  the  foil  on  the  point  of  the  plugger,  and  at  the 
same  time  prevents  any  exhaustion  of  the  battery. 

This  instrument  is  operated  by  three  Bunsen  cells,  charged  with 
dilute  sulphuric  acid  and  bichromate  of  potash, — the  cups  requiring 


LOCAL    TREATMENT  OF  DENTAL    CARIES. 


351 


to  be  filled  once  a  week.  M,  the  clock-work  for  breaking  the  cur- 
rent automaticall}^  runs  one  hour  from  the  winding.  In  some  of 
the  instruments  furnished  by  the  inventor,  this  clock-work  arrange- 
ment is  replaced  by  simpler  means. 


From  the  consideration  of  the  introduction  of  the  filling,  we  may 
now  pass  to  the  processes  of  finishing.  These  consist  in  condensing 
the  surface  thoroughly,  in  filing  the  plug  into  such  shape  and  rela- 
tion as  shall  accord  with  requirements,  and  in  giving  it  a  jewelly 
polish. 

To  accomplish  these  ends,  the  operator  will  need  files,  conden- 
sers, burnishers,  pumice-  and  rotten-stone,  rouge,  strips  of  tape  or 
wash-leather,  pieces  of  wood,  etc.  ;  that  is  to  say,  he  will  find  useful 
any  means  which  shall  conduce  to  the  required  ends.  As  condensing 
instruments  are  concerned,  they  find  representation  in  the  pluggers 
with  the  serrations  filed  off.  Much  pressure,  however,  being  brought 
oftentimes  to  bear  upon  such  instruments,  especially  where  the  mallet 
is  not  used,  the   manufacturer  in  preparing   them    considers  such 

Fig.  118.— FixisHiNG  Files. 


requirements,  and  by  so  much  enlarges  the  size  of  the  shank  over 
that  of  the  pluggers. 

Files   used   in   finishing   are   prepared   in  the  greatest   possible 
variety.     The  separating  files,  figured  on  a  foregoing  page,  are  indis- 


352 


ORAL  DISEASES  AND   SURG  ERF. 


pensable  for  use  on  the  front  teeth.  Fig.  118  represents  forms  of  files 
that  are  found  useful  in  almost  every  position.  Fig.  119  exhibits  files 
prepared  in  the  bur  form.  These  latter  have  application  in  the 
cutting  down  of  crown  plugs,  and  accomplish  their  work  with  a 
nicety  and  finish  which  seem  to  prove  them  perfect.  Fig.  119 
shows  also  the  handle  of  these  instruments.     These  bur  files,  when 

Fig.  119. — Bur  and  Wheel  Ftles. 


worked  by  the  pneumatic  or  the  lathe  engine,  are  revolved  with  a 
velocity  which  enables  them  quickly  to  cut  into  shape  the  hardest- 
made  plug,  Dr.  Bon  will   claiming  for    his  instrument    a    rotatory 


Fig.  120. — Skt  of  Burnishers. 


power  of  four  thousand  to  the  minute.     Worked  by  hand,  however, 
these  files  quickly  enough  accomplish  the  work,  and  will  prove  in 


LOCAL    TREATMENT  OF  DENTAL    CARIES.       353 

such  manner  of  use  sufficiently  satisfactory  to  the  majority  of  prac- 
titioners who  may  use  them.  The  manner  of  employing  the  various 
forms  of  files  does  not  merit  space  for  description,  as  it  is  a  matter 
self-suggestive. 

Burnishing  instruments  will  also  be  found  of  many  patterns,  the 
designs  corresponding  with  requirements.  Fig.  120  represents  a  set 
of  these  instruments  which  will  be  recognized  by  the  experienced  to 

Fig.  121. — Pokte  Polishers. 


comprise  all  the  forms  for  which  there  is  real  necessity.  Indeed,  it 
would  be  quite  possible  to  do  without  Nos.  1,  3,  5,  and  T  :  such  a 
set  costing,  however,  not  over  six  dollars,  the  outlay  for  the  whole 
would  soon  be  found  covered  by  the  extra  convenience.  No  bur- 
nishing instrument  except  that  made  from  the  very  finest  of  steel 
is  worth  possessing.  The  use  of  the  burnisher  is  both  to  condense 
and  to  polish  the  face  of  a  filling.  Jt  is  to  be  used  in  connection 
with  the  file,  the  filling  being  alternately  filed  and  planished. 

Among  other  instruments  found  convenient,  if  not  absolutely 
necessary,  in  the  process  of  finishing,  are  porte  polishers.  Fig.  121 
represents  a  set  of  three.  These  carriers  enable  the  operator  to  fix 
splints  of  wood,  upon  which  he  carries  pumice-  or  rotten-stone,  at 
any  angle  found  convenient  in  working.  The  use  of  pumice-stone 
so  applied  represents  the  finest  file,  and  is  found  of  the  highest  im- 
port in  securing  a  proper  surface.  A  porte  polisher  of  satisfactory 
yet  inexpensive  character  is  made  by  soldering  together  at  right 
angles  two  tubes  of  silver  or  of  tin  of  a  size  fitted  to  support  a  handle 
of  wood  and  the  splint.  As  a  porte  polisher,  the  pneumatic  engine 
of  Green  seems  to  possess  an  advantage  in  what  might  be  termed 
a  reciprocal  motion  belonging  to  its  mechanism.     Not  only  does  it 

23 


354  OBAL  DISEASES  AND  SURGERY. 

revolve  a  body,  but  with  equal  facility  drives  it  forward  and  back- 
ward. 

A  cavity  being  filled  with  gold,  it  is  felt  to  be  a  necessity  to  secure 
a  surface  of  sufiBcient  polish  to  resist  the  absorption  of  moisture 
before  the  removal  of  the  napkin.  This  is  done  with  the  bur- 
nisher, a  polish  being  at  once  taken,  provided  the  gold  has  been 
solidly  packed  ;  should  a  polish  not  be  taken,  then  the  operator 
is  to  go  over  the  surface  with  a  condenser,  using  either  hand- 
pressure  or  the  mallet.  These  manipulations  of  burnishing  and 
condensing  in  alternation  are  to  be  repeated  until  the  protecting 
polish  is  secured. 

The  condensation  of  a  filling  is  most  conveniently  effected  through 
the  aid  of  the  mallet.  The  blows  struck  are  at  first  to  be  very 
light,  that  thus  unequal  consolidation  may  be  avoided  ;  it  is  best 
that  at  the  commencement  the  instrument  be  directed  about  the 
circumference  of  the  plug,  the  centre  being  gradually  approached,  the 
operator  thus  avoiding  the  drawing  of  the  metal  from  the  parietes, — 
an  important  matter,  as  a  very  little  experience  will  not  fail  to  show. 
Having  made  such  condensation  of  the  surface,  it  is  to  be  followed 
by  the  burnisher  or  file,  as  shall  seem  indicated.  It  is  always  most 
important  to  avoid  any  overhanging  of  the  walls  by  the  gold  ;  this 
implies  that  a  cavity  should  not  be  overfull.  In  crown  fillings,  this 
is  a  not  uncommon  fault.  Where  it  is  seen  to  exist,  the  bur  file 
may  follow  the  burnisher.  The  face  of  a  crown-plug  should,  when 
finished,  be  concave,  corresponding  with  the  aspect  of  the  surface 
of  which  it  forms  a  part.  In  securing  such  relation  of  parts,  the 
filling  will  always  be  found  of  more  resisting  surface  if  the  cutting 
down  has  been  done  little  by  little,  the  burnisher  being  used 
very  frequently  as  such  cutting  is  eff'ected.  The  final  finish  is 
given  to  a  plug  by  the  alternate  use  of  the  burnisher  and  the 
porte  polisher,  pumice-  or  Arkansas-stone  being  first  used,  and  after 
this  rotten-stone,  crocus,  or  rouge ;  through  such  means  the  sur- 
face of  a  plug  may  be  made  as  solid  and  polished  as  the  molten 
metal. 

In  finishing  proximal  fillings,  wherever  situated,  it  is  felt  to  be 
desirable  ro  give  such  plane  to  the  surface  as  shall  render  it  self- 
cleansing  :  this  is  most  simply  secured  by  making  the  metal  corre- 
spond with  the  V-shaped  cuts  which  have  been  advised  :  in  the 
anterior  teeth  this  is  effected  with  all  convenience  by  the  use  of 
the  convex  separating  file  as  seen  in  Fig.  79.  In  the  posterior  teeth 
the  operator  will  select  from  his  case  any  files  that  are  suitable  and 


LOCAL    TREATMENT   OF  DENTAL    CARIES.        355 

easy  of  manipulation.  Among  the  forms  exhibited  in  Fig.  85  he 
may  find  himself  suited.  Cuts  made  in  the  Y-shape  are  not  entirely 
void  of  objection.  It  is  not  unfrequently  the  case  that  the  particles 
of  food,  instead  of  passing  quickly  and  cleanly  over  the  surface,  tend 
to  pack  in  the  interspace,  thus  being  a  source  of  discomfort  to  the 
patient,  and  at  times  provocative  of  a  species  of  chronic  ulitis. 
Such  jamming  is,  however,  oftentimes  the  result  of  the  manner  of 
filing, — a  matter  which  soon  comes  to  be  corrected  by  a  growing 
experience.  In  place  of  such  packing  of  the  ingesta  being  an  objec- 
tion, it  is  with  force  argued  by  many  that  it  is  a  positive  good,  com- 
pelling, through  the  discomfort  induced,  that  attention  to  absolute 
cleanliness  which  is  the  object  of  the  space. 

A  proximal  plug  filed  into  the  required  relation,  the  polishing  and 
finishing  follow  as  with  the  crown-plug.  Strips  of  holly  wood, 
corundum  tape,  or  wash-leather,  wet  and  dipped  into  pulverized 
pumice,  or  twists  of  ordinary  candle-wick  used  in  a  similar  manner, 
will  be  found  valuable  adjuncts,  affording  a  fineness  of  surface  wiiich 
cannot,  without  a  much  greater  amount  of  labor,  be  had  through 
the  instrumentality  of  partl^^-worn  files.  These  strips  are  used 
simply  by  drawing  them  back  and  forth  over  the  surface  to  be 
smoothed.  Rotten-stone  and  rouge  or  the  peroxide  of  tin  are  em- 
ployed upon  the  strips  for  the  finish. 

In  finishing  contour-fillings,  such  regard  as  may  be  had  is  to  be 
given  to  self-cleansing  properties.  Such  plugs  are  filed  into  a  shape 
corresponding  with  the  natural  contour  of  the  tooth.  That  they 
may  render  any  prolonged  service,  they  must  have  such  solidity  as 
shall  enable  them  to  bear  the  strain  endured  by  the  original  parts. 
The  process  of  finishing  is  the  same  in  principle  as  that  employed 
in  the  cases  just  described.  In  shaping  the  articulating  face  it 
is  necessary,  however,  that  special  regard  be  given  to  the  contact 
of  the  opposing  tooth  or. teeth, — a  matter  which  frequently  demands 
much  time  and  care.  In  shaping  contour-fillings,  it  is  generally 
found  convenient  to  use  delicate  slabs  of  the  Arkansas  or  similar 
stone,  rubbing  thus  from  the  gold  every  scratch  or  indentation. 
Finish,  it  is  to  be  remembered,  is  the  expression  of  stability  and  force 
in  a  contour-filling,  as  it  is  only  a  solid  and  reliable  filling  that 
is  capable  of  taking  a  fine  finish. 

A  reaction  from  the  plane  to  the  contour  form  of  filling,  evidently 
just  now  setting  in,  will  not  unlikely  carry  such  manner  of  operating 
into  extremes.  Contour-fillings  certainly  exhibit  mechanical  skill 
on  the   part  of    an   operator;    and,   besides,   such  plugs    have  an 


356  ORAL  DISEASES  AND   SURGERY. 

advantage  in  the  lost  surface  they  restore.  If  solidlj  made,  and  if 
the  joints  are  perfect,  it  would  be  true  that  as  the  matter  of  cleanli- 
ness is  concerned,  teeth  thus  restored  would  be  in  no  worse  condition 
than  in  their  original  state.  A  query  may,  however,  very  justly 
arise  as  to  whether  surfaces  may  not  be  made  to  the  improve- 
ment of  parts  of  certain  condition  as  naturally  existing.  The 
experience  and  judgment  of  the  author  favor  the  inclined  plane. 
Like  maily  other  excellent  things,  such  plane  is,  however,  fre- 
quently carried  to  excess :  the  attainment  of  the  highest  good 
is  to  secure  a  surface  sufficiently  inclined  to  forward  anything  strik- 
ing against  it,  while  at  the  same  time  preserving  all  the  cutting 
face  possible.  Contour-filling,  as  is  recognized,  leaves  no  dentine 
exposed. 

In  concluding  the  subject  of  filling  the  decayed  crowns  of  teeth 
with  gold,  the  student  is  reminded  that  the  principles  which  are 
to  govern  him  are,  "That  all  difficult  cavities  are  to  be  converted 
into  those  of  simple  form  ;  and  that  space  is  al\va3"S  to  be  secured, 
either  by  the  file,  chisel,  or  pressure,  which  shall  give  the  required 
room  for  manipulation." 

The  File  as:  a  prophylactic  and  curative  agent. 

Having  upon  former  pages  described  the  use  of  the  file  from  the 
strictly  mechanical  standpoint,  we  pass  now  to  the  consideration  of 
the  instrument  as  a  prophylactic  and  curative  means. 

In  the  process  of  preparing  proximal  cavities  for  filling,  it  has 
been  seen  that  in  very  many  cases — indeed,  in  the  great  majority — 
the  dentine  of  the  teeth  has  been  exposed,  and  that  afterward  no 
steps  have  been  taken  for  its  protection.  This  absence  of  care  arises 
from  the  experience  that  such  dentine  left  to  itself  does  not  tend  to 
decay,  but  that  when  the  operation  of  filing  has  been  accomplished 
with  judgment  and  the  proper  delicacy,  it  seems  in  quite  as  resistive 
a  condition  as  before  being  denuded. 

Acting  on  the  premises  of  such  an  experience,  it  is  to  be  com- 
mended not  only  that  conditions  of  incipient  caries  be  filed  away, 
but  also  that  in  irregular  dentures  the  irregularities  which  invite 
disease  be  treated — in  propiiylaxis — in  like  manner.  Of  all  the 
various  operations  performed  upon  the  teeth,  none,  certainly,  demands 
more  experience  than  this  we  are  now  studying ;  or  if  experience  is 
to  be  replaced,  it  may  only  be  by  a  judgment  which  possesses  the 
fullest  recognition  of  the  requirements. 


LOCAL    TREATMENT  OF  DENIAL    CARIES.        357 


Fig.  122. 


It  is  to  be  borne  in  mind  as  a  cardinal  principle  that,  in  prophy- 
laxis, dentine  is  never  to  be  uncovered  except  the  surface  exposed 
ma}' be  made  self-cleansing;  hence  it  is  at  once  seen  that  certain 
positions  of  decay  preclude  this  treatment ;  cavities,  for  example, 
occupying  sulci  upon  the  grinding  faces  of  the  molars. 

A  second  principle  which  is  to  possess  its  weight  with  the  operator 
lies  in  the  premise  that  the  file  is  not  to  be  used  upon  teeth  the 
conformation  and  relation  of  which  will  not  insure  continuance  of 
the  position  in  which  the  operation  leaves  them.  This  second  might 
be  considered  but  an  iteration  of  the  first  premise  if  it  were  not  so 
well  known  that  filed  teeth,  unless  wedged,  tend  to  change  position. 
Hence  the  judicious  use  of  the  file  implies  not  only  a  present,  but 
the  future.  In  Fig.  122  an  illustration  is  given  of  what  is  meant. 
Observing  the  bicuspid  and  approx- 
imating teeth  in  this  diagram,  it  is 
seen  that  between  the  first  molar  and 
the  second  bicuspis  the  file  has  been 
passed  directly  through  to  the  gum, 
the  space  being  the  same  behind  as 
in  front,  and  at  the  necks  as  at  the 
cutting  edges ;  this  is,  as  seen,  a 
free  and  open  space.  Referring  now 
to  the  cuspo-bicuspis  relation,  it  is 
shown  that  these  teeth,  which  have 

been  filed  in  a  precisely  similar  manner,  have  fallen  together,  and  so 
fallen  as  clearly  to  exhibit  the  impossibility  of  keeping  them  cleansed 
unless  by  a  care  that  very  few  persons  are  found  to  give  to  the 
teeth.  Teeth  so  filed  are  cut  only  to  their  injury,  unless,  indeed,  it 
might  be  that  by  the  act  of  cutting  such  response  was  excited  from 
the  pulp  as  to  eventuate  in  a  resistive  consolidation  of  the  structure, 
— a  result  that  it  would  scarcely  be  wise  to  anticipate,  being  certainly 
possible,  but  scarcely  probable. 

Eburnification  or  vitrifaction,  the  process  by  which  exposed  and 
irritated  dentine  becomes  self-protective,  has  been  described  on  a 
preceding  page.  An  operator,  before  resting  anticipations  of  the  cure 
of  superficial  caries  on  the  file,  is  to  appreciate  well  the  responsive 
efforts  with  which  the  manipulations  are  likely  to  meet. 

Teeth  of  soft  character  are  perhaps  never  found  so  tolerant  of  the 
file  as  are  those  of  more  solid  structure,  and  when  cut  not  unfre- 
quentl}'^  give  way  as  by  a  process  of  invisible  ulceration,  just,  indeed, 
as  caries  in  bone,  while  so   commonly  cured   through   the   relief 


358  ORAL  DISEASES  AND   SURGERY. 

afforded  from  operative  means,  will  be  seen  at  times  and  under 
adverse  systemic  influences  to  have  had  the  little  force  which  existed 
destroyed  by  the  operation.  This  is  the  case  with  the  tooth  where 
the  pulp  life,  instead  of  reacting,  succumbs  to  the  irritation. 

Appreciating  these  conditions  influencing  the  use  of  the  file,  our 
study  may  lead  us  to  an  observation  of  examples  illustrative  in  the 
direction. 

As  a  first  of  such  examples,  attention  may  be  directed  to  surfaces 
of  contact  between  teeth  of  the  two  dentures.  A  permanent  tooth 
manifesting  expressions  of  proximal  change  and  being  adjoined  by 
, a  tooth  of  th§  first  set,  which  tooth  exhibits  itself  in  the  relation  to 
be  a  cause  of  offense,  may,  if  such  first  tooth  is  not  too  sensitive, 
find  relief  by  filing  directed  exclusively  to  the  latter  organ.  The 
use  of  the  file  is  here  and  there  oftentimes  made  available  as  the 
approximal  relations  of  the  six-year  molar  and  second  deciduous 
are  concerned,  or  as  are  related  the  temporary  cuspis  and  a  perma- 
nent bicuspis,  or,  still  again,  as  the  permanent  superior  incisores 
centrales  and  milk  laterales  are  seen  to  be  sources  of  mutual 
injury.  Milk  teeth,  it  is  to  be  recognized,  may  not,  however, 
always  be  filed  with  impunity:  in  very  irritable  temperaments 
spasms  might  very  readily  be  found  to  result  from  such  an 
operation. 

Referring  now  to  the  six  superior  anterior  teeth  of  the  permanent 
set,  it  is  to  be  recognized  that  caries  attacking  the  proximal  surfaces 
is  not  an  infrequent  condition,  being  excited,  in  part  at  least,  as  has 
been  suggested,  not  only  by  the  lodgment  of  detritus,  but  by  a  motion 
attendant  on  the  masticatory  act,  which  motion  abrades  or  cracks 
the  enamel  of  these  surfaces. 

To  discover  incipient  disease  of  the  proximal  faces  of  teeth  in 
the  very  earliest  stage  is  a  matter  of  no  difficulty.  A  waxed  thread 
passed  into  the  interspaces  exhibiting  roughness  of  the  surface,  or 
a  sharp  excavator  demonstrating  the  existence  of  a  process  of  soften- 
ing, readily  enough  gives  cognizance  of  the  affection.  Teeth  so 
conditioned,  if  reasonably  hard  and  of  such  shape  as  to  permit 
of  self-sustaining  separation,  may  be  cut  with  the  prospect  of  a 
permanent  cure.  If,  on  the  contrary,  the  structure  be  soft,  and  if 
the  relation  be  such  that  continued  separation  is  not  to  be  secured, 
then  it  must  of  necessity  prove  the  better  practice  to  depend,  at  a 
period  somewhat  later,  on  separation  by  means  of  wedges  and  the 
clearing  out  and  filling  of  a  cavity  that  may  ensue.     In  the  interim. 


LOCAL    TREATMENT  OF  DENTAL    CARIES.        359 

however,  the  disease  is  to  be  held  much  la  abeyance  by  means  of 
waxed  floss  silk  passed  frequently,  by  polishing  with  soft  powders 
used  as  for  dressing  fillings,  and  by  attention  to  every  condition 
vs^hich  may  be  recognized  as  an  agent  of  offense. 

In  filing  away  incipient  caries,  inclined  surfaces  are  always  to  be 
aimed  at.  Such  surfaces  secured  and  maintained,  the  parts  from 
necessity  are  made  self-cleansing ;  the  act  of  mastication  itself  is 
made  a  cleansing  act.  Especially  is  this  so  where  the  denuded  sur- 
face has  been  burnished  and  polished  with  that  care  which  is  as 
indispensable  as  the  plane  itself. 

To  prevent  filed  teeth  from  falling  together,  it  is  requisite  to 
secure  at  some  position  surfaces  of  abutment;  such  a  surface,  when 
possible,  is  to  be  maintained  at  the  necks  of  the  teeth.  This  abutting 
surface  is,  however,  in  itself  an  ill, — but  it  is  the  smallest  part  of  a 
common  ill  combated.  When  the  absence  of  abutment  of  the  teeth 
at  the  neck  does  not  allow  of  the  sustaining  points  being  here 
secured,  it  may  be  proper  first  to  press  the  teeth  asunder  by  means 
of  a  wedge  of  wood  as  directed  in  the  chapter  on  fillings,  and,  having 
thus  the  enamel  in  front  intact,  cut,  by  means  of  a  safe-edged  separ- 
ating file  of  convex  face,  a  V-space  the  base  of  which  looks  into  the 
oral  cavity.  The  wedge  removed,  and  the  teeth  coming  together, 
it  is  plainly  seen  that  only  the  enamel-covered  edges  left  in  front  may 
impinge.  The  diagram.  Fig.  78,  right  side,  exhibits  surfaces  rendered 
self-cleansing. 

The  objection  to  the  employment  of  the  file,  prevalent  among 
the  community,  has  arisen  from  the  fact  that  the  instrument  has 
been  used  with  so  little  judgment :  perversions,  both  pathological 
and  artistic,  have  been  witnessed  as  more  commonly  the  result  than 
good;  hence  in  reasonable  data  has  this  prejudice  had  its  origin. 
Such  ill,  however,  resides  no  more  in  the  instrument  of  itself  than 
does  discord  in  the  keys  of  the  piano,  and  nothing  is  required  but 
the  intelligent  touch  to  disabuse  the  minds  of  the  people  of  such 
prejudice. 

That  sensibility  of  dentine  and  irritation  of  the  dental  pulp  are 
frequently  witnessed  in  connection  with  filing  teeth,  is  a  fact  too 
common  to  be  denied.  Indeed,  many  sets  of  teeth  have  been 
rendered  permanently  useless  from  such  results;  but  here  error 
in  judgment  has  influenced  the  operation.  Another  objection  urged 
against  filing  has  been  thought  to  lie  in  chronic  ulitis  engendered 
by  the  pressure  of  ingesta.     Teeth  filed  as  exhibited  in  diagram. 


360  ORAL  DISEASES  AND   SUBGERY. 

Fig.  122,  could  but  result  in  such  conditions ;  but  the  fault  here,  as 
in  the  example  above,  lies  with  the  operator.* 

Under  the  head  of  Odontalgia  we  may  now  consider  conditions 
which  complicate  the  subject  of  filling  teeth  ;  understanding  which 
complications,  the  matter  of  root-filling  intelligently  follows, 

*  A  work  has  lately  been  issued  entitled  "Prevention  of  Decay  of  the 
Teeth,"  written  by  Kobert  Arthur,  M.D.,  of  Baltimore,  in  which  the  subject 
of  the  file  as  a  prophylactic  and  curative  agent  is  discussed  at  much  length. 


( 


\ 

1 


CHAPTER    XI  Y. 


THE    TEETH    AND    THEIR   DISEASES. 


ODONTALGIA. 

Under  this  common  head  we  shall  consider  all  the  various  pains 
in  the  teeth,  however  induced.  The  term  comes  from  the  two  Greek 
roots,  odous,  a  tooth,  and  algos,  pain — odontalgia,  toothache,  or  pain 
in  a  tooth. 

The  causes  of  toothache  may  be  classed  under  the  following 
heads : 

1.  Sensitive  dentine. 

2.  Direct  or  indirect  exposure  of  the  pulp  to  sources  of  irritation. 

3.  A  diseased  state  of  the  periodoiiteum. 

4.  Confinement  of  pus  and  gas  in  the  pulp  cavity. 

5.  Granules  of  osteo-dentine  in  the  pulp. 

6.  Sympathy. 

t.   Recession  and  absorption  of  the  gum  and  alveolus. 

1.  Sensitive  Dentine. — Some  teeth,  immediately  on  the  breaking 
down  of  the  enamel  and  the  consequent  exposure  of  the  dentine, 
become  exceedingly  sensitive,  or,  in  other  words,  exhibit  themselves 
as  peculiarly  susceptible  to  the  influences  of  irritating  agents.  This 
impressibility  is  attempted  to  be  explained  by  the  most  dissimilar 
hypotheses,  few  subjects  connected  with  the  teeth  having  elicited 

more  discussion  and  controversy.* 

%  

*  An  observation  of  the  pulps  of  certain  teeth  which  have  been  exposed  to 
irritation  in  cavities  unopened  as  well  as  open  will  exhibit  the  existence  of 
fungoid  excrescences.  Only  very  lately  it  has  happened  to  the  author  to  open 
several  teeth  which  had  been  partly  destroyed  by  caries,  the  pulp  chamber, 
however,  being  intact ;  in  two  of  these  cases  a  magnifying  glass  of  very 
ordinary  power  exhibited  thread-like  excrescences  of  most  minute  and  tibrilla- 
like  appearance,  passing  in  clusters  from  the  .surface  of  that  portion  of  the 
body  of  the  pulp  adjoining  the  cavity  of  decay.  These  excrescences  were  in 
each  instance  of  a  pearly-white  color,  and  might  well  have  been  likened  to 
bundles  of  the  most  delicate  cobweb.  It  is  suggested  to  the  attention  of  the 
microscopist  that  it  may  be  possible  that  such  excrescences  passing  into  the 

(361) 


362  ORAL  DISEASES  AND   SURGERY. 

In  teeth  thus  sensitive,  the  operation  of  excavation  is  occasionally 
found  so  painful  as  to  be  quite  unbearable,  and  may  only  be  accom- 
plished through  the  employment  of  means  that  shall  lessen  such 
sensibility.  Even  sweets  taken  into  the  mouth,  or  cold  or  hot 
drinks,  or  acids,  the  latter  particularly,  will  occasionally  provoke 
pain  in  such  teeth.  Instances  quite  numerous  exist  where  such 
dentinal  sensibility  is  continuous,  the  pain  being  of  a  dull  annoying 
character  existing  quite  independent  of  foreign  agents  of  offense. 
In  these  latter  cases  the  exciting  cause  must  be  looked  for  in  some 
irritative  condition  existing  in  the  oral  fluids  :  these  may  be  too 
acid  or  too  alkaline.  Tests,  however,  are  here  easily  made  with 
the  aid  of  litmus  or  turmeric  paper,  and  specific  remedies  accordingly 
may  have  immediate  employment. 

As  direct  applications  to  teeth  sensitive  from  the  nature  of  their 
organization,  medicinal  obtunders  in  the  greatest  variety  are  sug- 
gested. Of  these  perhaps  the  most  permanently  effective  is  arsenic: 
this  application,  however,  possesses  an  objection  in  ill  results  almost 
certain  to  accrue  to  the  dental  pulp  which  render  the  use  of  it  en- 
tirely inadmissible ;  it  is,  nevertheless,  very  frequently  employed. 

Chloride  of  zinc  is  a  favorite  preparation,  and  where- used  imme- 
diately preparatory  to  excavating  will  be  found  commonly  to  answer 
most  satisfactoril3\  In  the  employment  of  this  agent,  as  in  that  of 
the  arsenic,  care  is  to  be  exercised  that  such  impression  be  not  pro- 
duced as  shall  unduh'  irritate  the  pulp  The  application  of  the 
chloride  of  zinc  is  variously  made.  A  common  mode  is  to  take  a 
deliquesced  preparation,  drop])ing  it,  when  it  may  conveniently  be 
done,  from  the  point  of  an  instrument  into  the  cavity,  which  cavity 

tubular  structure  have  beeu  mistaken  for  nerve-fibrilLne.  AVithout  qualifica- 
tion, however,  the  author  believes  that  exception  may  be  taken  to  the  doctrine 
that  nerves  pass  from  the  pulp  into  the  tubuli.  It  scarcely  seems  to  need  the 
microscope  to  demonstrate  the  correctness  of  such  an  opinion.  That  fibrillie, 
however,  may  be  found  in  teeth  of  loose  structure,  being  intertubular,  may 
readily  be  received  as  a  fact,  but  their  origin  is  to  be  sought  in  the  enamel 
membrane  and  not  in  the  pulp.  One  explanation  at  least  of  sensitive  dentine 
would  seem  to  be  found  in  the  relation  of  the  dentinal  circulation  to  the  pulp 
through  the  medium  of  the  halitus  of  the  chamber;  this  finds  (at  times) 
demonstration  in  the  marked  relief  so  commonly  gained  through  absorption 
from  the  cavity  of  all  moisture,  and  the  preservation  of  such  dryness  during 
the  process  of  cutting.  That  entire  dryness  in  a  dental  carious  cavity  is 
among  the  best  antidotes  to  sensibility  has  come  to  have  such  common  prac- 
tical recognition  that  a  large  class  of  the  most  experienced  operators  rely 
exclusively  upon  it. 


THE   TEETH  AND    THE  IB   DISEASES.  363 

has  been  previously  dried ;  the  parts  being  protected  from  any 
inroad  of  moisture  by  means  of  the  napkin  or  dam.  Another  mode 
consists  in  employing  a  pellet  of  cotton  saturated  with  the  zinc.  Still 
another  mode,  and  that  preferred  by  the  author,  consists  in  using  the 
crystals  direct,  a  few  of  these  being  placed  in  a  cavity  and  allowed 
there  to  deliquesce. 

The  almost  immediate  result  of  zinc  applied  to  a  sensitive  cavity 
is  the  production  of  sharp  pain  ;  this,  however,  is  commonly  found 
to  disappear  in  from  one  to  two  minutes,  when,  the  sensibility  having 
been  obtunded  by  the  action  of  the  agent  upon  the  superficies  of  the 
cavity,  excavation  may  i)ainless]y  proceed  to  that  extent  of  depth  to 
which  the  salt  h:is  acted.  Reapplications  may  be  made  as  found 
necessary,  although  it  is  to  be  recognized  that  the  fewer  one  can 
get  along  with  the  better  for  the  subsequent  health  of  the  tooth. 

Chloride  of  zinc  in  full  strength  kills  immediately  the  part  to 
which  it  is  applied;  diluted,  it  is  very  apt  to  irritate  only,  increasing 
the  very  sensibility  it  is  used  to  destroy.  Where  the  pain  attend- 
ant on  the  application  of  the  zinc  is  objectionable  to  the  patient,  it 
may  he  in  great  pnrt  obtunded  by  a  preliminary  employment  of  the 
solution  of  sulphate  of  atropia. 

Another  mode  is  found  in  mixing  the  two  agents  together  in  equal 
parts,  and  employing  tlie  combination. 

Agents  having  no  ulterior  ill  influence,  and  which  frequently 
render  all  required  service,  are  found  in  such  preparations  as  creasote, 
chloroform,  an  ethereal  solution  of  tiie  ter-chloride  of  gold,  aconite, 
sulphate  or  acetate  of  morphia,  chromic  acid,  atropia,  nitrate  of  silver, 
glycerole  of  thymol  used  warm,  etc.  It  is  sometimes  found  that 
by  sealing  up  in  a  cavity  for  one  or  two  hours  either  the  sulphate 
of  atropia  or  morphia,  the  former  preferably, — but  always  to  be  used 
Avith  great  care, — excavation  may  be  accomplished  with  entire 
absence  of  pain.  Cauterizing  the  cavity  with  a  point  of  the  nitrate 
of  silver  frequently  answers  the  same  end.  A  mixture  of  equal  parts 
of  tincture  of  aconite  and  a  saturated  solution  of  iodine  is  highly 
recommended  as  an  excellent  cauterant  and  obtunder.  The  value  of 
any  or  all  of  these  agents  is  not,  however,  to  be  overestimated,  as 
a  very  little  experience  will  be  sure  to  make  evident.  What  will  be 
found  to  answer  most  satisfactorily  in  one  case  may  have  little  effect 
in  another. 

A  means  of  overcoming  the  difficulty  which  is  perhaps  more  reliable 
than  the  employment  of  obtunding  agents,  consists  in  using  very 
sharp  excavators  and  by  rapid  motion  making  deep  cuts  sweep- 


364  ORAL  DISEASES  AND   SURGERY. 

ing  the  circumference  of  the  cavity;  in  acid  mouths,  where  the 
carious  mass  is  mostly  made  up  of  semi-devitalized  animal  matter, 
such  treatment  will  commonly  prove  so  satisfactory  that  upon  the 
removal  of  a  superficial  horny  layer  all  sensibility  will  be  found  to 
have  disappeared.  The  success  of  this  manner  of  treatment  does 
not,  however,  apply  so  happily  in  alkaline  mouths  or  in  the  case  of 
very  hard  teeth.  Indeed,  it  may  be  said  that  in  such  dense  teeth 
zinc  alone  is  the  only  agent  yet  known  which  invites  any  special 
sense  of  reliance. 

Sensibility  of  dentine  is  also  at  times  found  to  be  dependent  not 
on  a  strictly  localized  hypersesthesia,  but  on  true  inflammation. 
Here  the  indication  is  for  precisely  the  treatment  required  for  in- 
flammation in  general. 

In  directing  treatment  to  a  sensitive  cavity,  it  is  most  necessary 
also  to  distinguish  between  the  common  sensibility  and  sensibility 
depending  on  exposure  of  the  dental  pulp.  Attention,  it  will  be 
recalled,  was  on  a  former  page  directed  to  cornuae  of  the  pulp  cavity, 
which  in  certain  instances  are  found  quite  nearly  to  approach  the 
surface.  Such  distinction,  however,  is  generally  easily  enough  made 
through  the  aid  of  an  exploring  instrument, — an  excavator  or 
nerve-plugger  being  used ;  if  at  any  point  there  is  exposure  of  the 
pulp,  the  touch  of  the  instrument  cannot  fail  to  distinguish  it,  as  the 
pain  induced  by  the  contact  would  not  be  found  to  apply  to  other 
parts  of  the  cavity. 

Another  condition  of  similar  import  exists  where  the  cavity  of 
decay  so  nearly  approaches  the  pulp  chamber  as  to  render  each 
stroke  of  the  instrument  an  agent  of  irritation.  This  condition  is  to  be 
recognized  in  the  depth  of  the  common  cavity,  and  in  the  tenderness 
being  most  associated  with  the  deepest  part.  These  cases  require 
great  delicacy  in  manipulation,  as  an  inadvertent  cut  would  most 
likely  plunge  into  the  substance  of  the  pulp. 

Etherization,  as  a  means  to  enable  the  operator  to  excavate  a  sen- 
sitive tooth,  is  not  unfrequently  resorted  to.  This  certainly  most 
efl^ectually  answers  the  purpose;  and  where  a  patient  may  be  easily 
aS'ected,  as  is  so  frequently  the  case,  a  few  inhalations  inducing  in- 
sensibility, there  would  seem  to  be  no  objection  to  its  employment. 
Anaesthesia  need  not,  of  course,  be  carried  to  any  profound  extent. 

The  administration  in  hyper-sensitive  cases  of  morphia  sub- 
cutaneously,  or  preferably  by  the  mouth,  is  a  practice  that  the 
annoyed  practitioner  need  not  hesitate  to  adopt.  To  an  adult  a 
quarter  of  a  grain  may  be  given  half  an  hour  before  commencing 


I 


THE   TEETH  AND    THEIR   DISEASES.  365 

the  excavation.  Bromide  of  potassium  answers  also  at  times  a 
very  reliable  purpose ;  twenty-five  grains  may  be  administered. 
Syrup  of  lactucarium  is  another  valuable  agent;  it  is  to  be  prescribed 
in  tablespoonful  doses.  All  of  these  means  affect  the  local  by  dimin- 
ishing the  general  sensibility.  Local  anaesthesia  as  induced  by  the 
ethereal  spray  is  by  some  highly  recommended, — the  atomized  fluid 
to  be  directed  in  continuous  current  upon  the  tooth  until  the  e.xcava- 
tion  is  completed  ;  risk  to  the  pulp  would  seem,  however,  to  be 
associated  with  the  operation. 

Viewing  sensitive  dentine  as  a  cause  of  odontalgia,  the  operator 
finds  his  most  permanent  means  of  cure  in  the  introduction  of  a  fill- 
ing into  the  cavity.  Another  means  resorted  to,  as  a  temporary  treat- 
ment, is  the  excavation  and  polishing  of  the  surface.  Still  others, 
the  cauterization,  as  above  suggested,  with  the  solid  nitrate  of  silver, 
or  the  use  of  the  various  other  agents  mentioned.  A  method  very 
satisfactory  where  the  parts  are  very  sensitive  consists  in  introducing 
into  the  unexcavated  cavity  a  filling  of  oxychloride  of  zinc.  The  sensi- 
tive grooves  so  often  met  with  across  the  neck  portion  of  the  face  of 
the  teeth  are  frequently  to  be  most  happily  treated  by  the  occasional 
repetition  of  the  polishing  of  the  surface  by  means  of  a  burnisher. 
Such  means  here  is  greatly  to  be  preferred  to  the  use  of  the  zinc. 

2.  Direct  or  Indirect  Exposure  of  the  Pulp  to  Sources  of  Irri- 
tation.— Reference  to  the  anatomy  and  relations  of  the  dental  pulp 
exhibits  it  as  a  body  composed  of  the  most  delicate  connective  tissue, 
in  which  ramify  nerves,  arteries,  and  veins.  This  body  is  lodged 
in  a  bony  cavity,  sufficient  only  in  size  for  its  comfortable  accommo- 
dation, and  for  the  halitus  or  fluid  which  surrounds  it.  Any  undue 
congestion  will  therefore  at  once  be  perceived  to  result  in  a  pressure, 
which,  from  the  presence  of  nerve-matter,  must  cause  acute  pain. 
This  appreciated,  the  pains  resulting  from  an  inflamed  pulp  must  be 
admitted  to  be  alike  in  general  character. 

A  pulp  need  not,  as  suggested  in  connection  with  applications 
employed  to  obtund  sensitive  dentine,  be  fairly  exposed  to  be  the 
subject  of  irritation. 

Cases  not  unfrequently  occur  where  the  plate  or  floor  of  a  cavity 
is  so  thin  and  so  altered  in  structure  that  it  will  yield  or  bend. 
In  these  instances  the  agencies  of  mastication  may  and  do  readily 
enough  force  this  plate  down  upon  the  pulp.  As  a  consequence  of 
such  pressure  we  have  irritation,  and,  it  may  be,  inflammation. 

Irritation  of  a  pulp  is  much  more  apt,  however,  to  be  associated 


366  ORAL  DISEASES  AND  SURGERY. 

with  its  exposure.  Here  everything  entering  into  the  cavity  is  a 
source  of  offense,  and  the  lesion  is  always  plainly  enough  discovera- 
ble; foreign  particles  coming  in  contact  with  such  an  exposed  pulp 
give  instant  and  perhaps  excessive  pain.  This  pain  may  quickly 
subside,  or  it  may  continue  for  hours  or  days ;  in  the  latter  case, 
inflammation  will  be  found  to  have  established  itself. 

A  free  and  open  break  into  the  pulp  cavity  is  attended  with  much 
less  pain  in  inflammation  of  the  organ  than  a  more  limited  exposure. 
In  the  first  case,  the  swelling  pulp  has  plenty  of  room,  and  conse- 
quently less  pressure  is  exerted  on  the  nerve-filaments.  In  the 
second,  the  protruding  congested  organ  quickl}'  becomes  strangulated, 
and  thus  pain  of  the  most  acute  and  severe  character  is  induced. 

The  treatment  of  an  exposed  pulp  is  of  a  twofold  character, — palli- 
ative and  radical.  The  first  consists  in  the  employment  of  soothing 
and  quieting  applications,  and  is  employed  principally  for  the  relief 
of  children.  The  second  implies  the  destruction  of  the  pulp;  this 
being  generally  eflfocted  through  the  instrumentality  of  escharotic 
applications.  To  quiet  an  irritated  pulp,  a  first  attention  is  to  be 
directed  to  the  removal  of  every  source  of  offense.  If  the  fluids 
of  the  mouth  be  irritative,  the  character  of  the  condition  must  be 
sought  for  and  corrected.  If  foreign  particles  have  found  their 
way  into  the  cavity  of  decay,  they  are  to  be  carefully  syringed  away 
with  warm  water.  Such  attention  niay  be  all  that  is  needed.  If 
not,  and  the  excitabilit}-  continues,  recourse  should  be  had  to  sooth- 
ing applications  :  the  tincture  of  hamamelis  applied  warm,  or  the 
oil  of  cloves,  or  creasote  much  diluted,  or  chloroform,  acOnite,  and 
laudanum,  in  equal  parts,  will  sometimes  act  very  happily,  particu- 
larly in  such  cases  as  depend  upon  excitation  unattended  with  inflam- 
mation. Where  evidence  of  congestion  or  vascular  excitement  of  any 
grade  exists,  lead-water  and  laudanum  will  frequently  act  like  magic. 
Persulphate  of  iron  and  tincture  of  iodine  are  found  sometimes  to 
act  very  happily  in  similar  conditions,  constringing  the  vessels,  and 
thus  breaking  up,  or  aborting,  as  it  were,  the  congestion.  In  the 
odontalgia  of  first  dentition,  it  is  well  that  parents  be  provided  with 
some  order  of  general  prescription.  A  very  good  one  is  as  follows,  to 
be  applied  by  saturating  a  small  piece  of  cotton  and  laying  it  loosely 
in  the  cavity: 

B. — Creasoti,  gtt.  vj  ; 

Tincturae  iodinii,  5j ; 

Liquoris  plumbi  subacetatis,  5j  I 

Chloroformi, 

Tincturae  opii,  aa  5ss.     M. 


THE    TEETH  AND    THEIR   DISEASES.  36T 

Such  a  prescription  is  suggested  on  the  principle  of  Dewees' 
carminative,  and  is  found  most  apt  to  meet,  in  some  one  of  its 
ingredients,  the  single  or  various  indications  that  may  be  present. 

Id  severe  inflammation  of  the  pulp,  it  may  be  necessary  to  con- 
join with  the  directly  local  the  more  indirect  means  of  medication: 
blisters  upon  the  nape  of  the  neck  will  frequently  result  in  speedy 
relief;  hot  pediluvia;  saline  cathartic  medicines,  as  the  sulphate  or 
carbonate  of  magnesia;  diaphoretics,  as  the  spirits  of  Mindererus, 
or  Dover's  powder;  or  diuretics,  as  the  nitre  preparations.  An  in- 
flammation of  tlie  dental  pulp,  if  not  too  far  advanced,  will  almost 
invariably  be  broken  up  by  the  administration  of  from  five  to  forty 
grains  of  bromide  of  potassium,  the  application  of  a  mustard  poultice 
to  the  back  of  the  neck,  and  a  hot  foot-bath,  continued  from  twenty 
minutes  to  half  an  hour. 

The  atropine  sulphas  is  also  to  be  relied  upon  as  an  invaluable 
agent  in  soothing  or  obtunding  the  pain  of  an  irritated  pulp.  If 
severe  inflammation  has  not  supervened,  and  if  the  trouble  has  been 
taken  to  rinse  from  the  cavity  any  detritus  of  offense,  the  instances 
will  be  found  few  indeed  where  it  will  not  afl'ord  almost  immediate 
relief. 

R. — Atropine  sulphatis,  gr.  v j  ; 
AqufB  destillatge,  ^j.     M. 

To  be  marked  "poison"  for  safety,  and  to  be  applied  precisely  as 
the  immediately  preceding  combination. 

A  cau-se  of  odontalgia  from  an  irritated  pulp  frequently  exists  in 
the  case  of  plugged  teeth,  from  pro.ximity  to  this  organ  of  the  mate- 
rial used  in  the  filling.  In  these  instances  a  constant  irritation  is 
kept  up  by  thermal  impressions  induced  by  the  presence  of  the  metal. 
If  inflammation  supervenes,  the  pain,  because  of  the  perfectly  in- 
closed condition  of  the  pulj),  becomes  of  the  most  acute  and  unbear- 
able character  ;  relief  will  generally  be  obtained  by  the  removal  of 
the  filling  ;  or,  if  this  should  not  succeed,  the  pulp  may  be  treated  as 
shortly  to  be  described.  Where  several  teeth  are  in  a  state  of  irri- 
tation from  such  a  cause,  and  confusion  of  distinct  location  is  thereby 
induced  (as  is  not  unfrequently  witnessed),  the  aifected  teeth  can  be 
made  clearly  to  designate  themselves  by  holding  cold  water  in  the 
month  ;  or,  what  is  even  better,  by  touching  each  particular  filling 
with  some  cold  steel  instrument.  The  increase  in  sensation  will 
commonly  be  thus  made  very  marked. 

The   operator   may  frequently  cure   such  teeth    by  introducing 


368  ORAL  DISEASES  AND  SURGERY. 

between  the  filling  and  floor  of  the  cavity  some  non-conducting  sub- 
stance,— a  piece  of  ordinary  quill,  a  particle  of  asbestos,  a  layer  of 
gutta-percha,  a  portion  of  the  Hill  stopping,  or  a  cap  of  gold. 

Still  another  source  of  irritation  to  the  dental  pulp  is  found  in 
the  wearing  down  of  the  teeth.  This  is  particularly  observed  in 
persons  who  use  large  quantities  of  tobacco,  or  in  such  as  have  the 
upper  and  lower  teeth  directly  articulating.  Happily,  however,  in 
the  generality  of  such  cases,  nature  antagonizes  the  external  influ- 
ence by  depositing,  in  quantities  as  needed,  secondary  or  osteo-den- 
tine  within  the  pulp  cavity,  at  the  same  time  contracting  this  organ, 
so  that,  in  proportion  as  the  tooth  wears  away  on  its  cutting  face, 
the  pulp  recedes,  and  casts  out,  as  its  protection,  this  secondary 
material.  It  is  a  beautiful  and  wonderful  process  of  offense  and  de- 
fense, and  commands  our  admiration. 

In  some  cases,  however,  and  these  not  a  few,  this  reparative  or 
protective  power  does  not  seem  to  exist ;  where  this  happens,  the 
pulp,  of  course,  soon  becomes  the  subject  of  irritation.  I  have  seen 
some  of  the  severest  cases  of  odontalgia  result  from  such  a  cause. 
The  only  cure  is  found  in  the  destruction  of  the  pulp.  To  apply 
arsenical  paste  under  such  circumstances  (see  radical  treatment  of 
pulp),  there  being  no  cavity  of  decay,  it  will  be  sufficient  to  lay  it 
in  the  cup-shaped  depression  commonly  existing  on  the  cutting  faces 
of  such  teeth  (the  result  of  the  more  rapid  wearing  of  the  inner  dental 
structure  than  of  the  outer  enamel  wall),  keeping  it  in  place  with  a 
covering  of  wax.  When  possible,  however,  it  is  much  better,  and 
more  speedy  practice,  carefully  to  drill  an  opening  into  the  pulp 
cavity,  and  with  a  delicate  needle  pick  the  arsenic  directly  into  the 
pulp.  The  death  of  the  organ  secured,  it  is  to  be  removed  from  its 
cavity  by  a  barbed  brooch,  and  its  place  supplied  with  gold.  Another 
mode  of  devitalizing  the  pulp  of  such  a  tooth  will  be  found  described 
in  connection  with  the  setting  of  pivot-teeth  (which  see). 

Improper  union  of  metals  in  the  filling  of  a  tooth  is  another  not 
unfrequent  source  of  irritation  to  the  dental  pulp.  Tin  foil  is  some- 
times placed  in  the  bottom  of  a  cavity,  and  the  operation  finished 
with  gold.  In  many  instances  (depending  not  unlikely  on  lack  of 
solidity  in  the  overlying  plug,  thus  admitting  moisture)  this  combi- 
nation produces  a  galvanic  action,  which,  if  not  removed,  will  quickly 
enough  destroy  the  pulp. 

Still  another  source  of  irritation  is  the  employment,  in  cavities 
more  or  less  in  proximity  to  the  pulp,  of  the  preparation  described 
as  tooth-bone :  the  chloride  of  zinc  used  in  excess  in  the  compound 


THE   TEETH  AND    THEIR  DISEASES.  369 

will  not  unfrequently,  within  a  very  few  hours  after  its  application, 
produce  an  inflammation  in  the  parts  almost,  if  not  entirely,  uncon- 
trollable.   Few  preparations  require  to  be  used  with  more  judgment. 

A  tooth  so  irritated  is  to  have  the  filling  removed,  and  perhaps  it 
will  always  be  found  the  best  practice  to  finish  the  death  of  the  pulp 
as  speedily  as  possible.  Asa  reverse  to  this,  it  is  to  be  recognized 
that  the  use  of  this  material,  as  has  been  explained,  will  sometimes 
be  provocative  of  just  sufficient  irritation  to  excite  the  secretion 
of  secondary  dentine,  thus  proving  the  best  practice  that  could  have 
been  pursued. 

A  pulp  may  give  every  evidence  of  being  in  an  irritated  condition 
where  the  osseous  integrity  of  the  tooth  is  perfect,  or  seemingly  so. 
Here  the  cause  may  be  still  strictly  local,  or  it  may  be  constitutional. 
BloAvs  received  by  a  tooth  often  result  in  such  irritation.  Atmos- 
pheric changes  will  sometimes  account  for  the  condition.  Pieces  of 
ice  brought  and  retained  in  contact  with  teeth  of  loose  structure  are 
frequent  sources  of  such  trouble.  Cracks  in  the  enamel,  induced 
from  whatever  cause,  and  permitting  the  impression  of  external 
influences  upon  the  dentine,  are  other  explanations.  In  a  constitu- 
tional direction,  rheumatism  is,  perhaps,  the  most  frequent  source ; 
after  this,  gout.  Reflex  or  radiated,  irritability  is  a  frequent  manifes- 
tation. This  is,  perhaps,  most  observable  in  the  hysterical  female. 
In  these  cases  no  special  practice  may  be  directed.  It  is  only  neces- 
sary to  discover  the  cause  of  offense,  wherever  and  however  situated, 
and,  if  possible,  remove  it.  In  the  odontalgia  of  gout,  dependence 
may  be  placed  on  the  exhibition  of  colchicum;  twenty  drops  of  the 
vinum  colchici  radicis,  three  or  four  times  a  day,  according  to  the 
urgency  of  the  symptoms,  may  be  given.  In  rheumatism,  I  know 
of  no  better  combination  than  the  following.  Its  administration, 
in  the  plethoric,  should  be  preceded  by  a  free  purging  with  a  saline 

cathartic. 

R. — Potassii  iodidi,  ^ss  ; 

Tincturae  colchici  radicis,  ^ss  ; 
Extracti  belladonnse,  gr.  vj ; 
Tincturae  guaiaci  compositae, 
Aquae  cinnamomi,  aa  §vj.     M. 

Sig. — To  the  adult  give  a  tablespoonful  three  times  a  day  in  a  little 
water ;  if  it  act  too  freely  on  the  bowels,  add  opium  q.  s. 

Functional  derangements  of  the  stomach  might  perhaps  deserve 
special  attention  as  reflex  or  radiated  odontalgia  is  concerned.    Any 

24 


370  ORAL  DISEASES  AND   SURGERY. 

one  who  has  ever  observed  the  relationship  existing  between  the 
pneumogastric  and  the  third  nerve,  as  manifesting  functional  stom- 
achic derangement  in  the  enlargement  of  the  pupil  of  the  eye,  will  be 
at  no  loss  to  associate  the  fifth  and  the  ninth  nerve.  Pure  neuralgia, 
as  the  term  has  common  signification,  is,  I  am  satisfied,  a  very  rare 
affection;  an  aching  nerve  will  generally  be  found  to  have  some 
lesion  outside  of  a  so-esteemed  idiopathic  condition,  and  the  lesion 
can  generally  be  discovered  by  closely  looking  after  it.  (See  Cause 
of  Sympathy.) 

Passing  now  to  the  consideration  of  the  same  conditions  as  refer- 
ence is.  had  to  a  tooth  required  to  be  filled,  we  will  be  impressed 
with  the  intelligence  and  observation  which  have  enveloped  the 
subject  with  the  light  of  a  common  and  reliable  experience. 

We  first  consider  the  condition  of  a  tooth  with  the  pulp  chamber 
nearly  exposed, — a  very  thin  lamina  of  dentine  existing  between  the 
two  cavities.  A  pulp  in  this  state  and  relation  has,  as  the  result  of 
its  subjection  to  irritating  influences,  one  of  three  sequelae.  It  may 
maintain,  just  as  it  normally  exists,  its  integrity  unaffected  by  the 
associations.  Second,  it  may  accept  just  that  extent  of  stimulation 
which  re-excites  the  formative  capacity,  increasing  the  distance  be- 
tween it  and  external  relations  by  a  secretion  consolidating  the 
overlying  dentinal  structure,  and  not  unlikely  attaching  a  secondary 
deposit  between  itself  and  tlie  original  boundary  of  its  cavity. 
Third,  it  may  succumb  to  the  irritation  which  its  force  may  not  be 
able  to  combat,  inflammation,  acute  or  chronic,  supervening,  and 
suppuration  resulting. 

Of  the  probable  results  in  all  such  cases,  a  reasonable  experience 
enables  the  observing  practitioner  to  form  a  fairly  reliable  estimate. 
To  maintain  that  all  pulps  in  such  relation  are  to  be  saved  is  to 
maintain  a  very  foolish  fallacy.  A  dental  pulp  is  a  part  of  the 
organic  life  with  which  it  is  found  related,  and  will  be  seen  to  have 
residing  in  it  tiie  impressions  of  the  system  at  large.  Thus,  a  first 
observation  necessarily  considers  the  state  of  health  in  the  individual 
who  may  be  the  patient.  As  here  shall  be  found  equilibrium  in 
excitability,  with  normal  nutritional  functions,  or  otherwise  degen- 
erative tendencies,  so  will  it  be  the  experience  that  attempts  to  save 
dental  pulps  are  responded  to  or  defied. 

Founding  the  practice  to  be  pursued  in  each  particular  case  upon 
an  experience  which  shall  come  of  such  observation,  if  indeed  it 
be  not  already  possessed  by  him  whose  judgment  acts  from  the 


THE    TEETH  AND    THEIR  DTS EASES.  371 

foundation  of  a  knowledge  of  the  principles  governing  all  such 
matters,  the  practitioner  determines  either  on  destroying  the  pulp 
and  removing  it,  or  on  an  attempt  to  preserve  it.  This  latter 
determination  is  always  to  have  the  benefit  of  any  doubt  which  may 
exist  in  the  mind  of  the  operator,  as  it  is  never  to  be  overlooked 
that  a  destroyed  pulp  signifies  necessarily  a  tooth  with  a  diminished 
vitality,  which  makes  it  a  body  more  or  less  foreign  to  the  parts 
with  which  it  is  in  association. 

The  destruction  of  a  pulp  decided  on,  the  operation  is  to  be 
accomplished  as  follows :  Should  irritability  and  pain  be  present,  they 
are,  inconvenient  and  possible,  to  be  first  subdued  by  such  means  as 
were  suggested  on  a  previous  page:  quiet  secured,  and  anesthesia 
existing,  by  reason  of  the  presence  of  the  morphia,  or,  still  better, 
the  atropia.  The  operator  uses,  of  what  is  known  as  nerve  paste, 
a  portion  corresponding  with  the  requirements  of  his  case ;  a 
piece  larger  than  the  ordinary  pin-head  being  seldom  needed.  This 
paste  is  dropped  gently  into  the  deepest  part  of  the  cavity  and  over- 
laid with  a  pellet  of  cotton,  which  is  made  protective  of  external 
influences  by  means  of  a  solution  of  gum  sandarac,  which  may  be 
dropped  upon  it  from  the  point  of  an  instrument  after  being  placed 
in  the  cavity,  or  otherwise  it  may  be  slightly  touched  to  the  solution 
previous  to  being  put  in  place.  A  very  little  experience  will  demon- 
strate that  it  is  undesirable  to  have  the  cotton  too  fully  saturated, — 
an  objection  that  is  sure  to  exist  if  some  little  care  is  not  taken,  the 
solution  being  absorbed  eagerly.  Formulae  for  nerve  paste  are 
variously  given,  but  the  author  has  found  every  reason  to  be  satisfied 
with  that  suggested  on  page  144.  In  very  irritable  conditions  it 
might  be  found,  however,  not  inadvisable  to  substitute  for  the  mor- 
phia the  atropise  sulphas. 

R. — Acidi  arseniosi, 

Morphine  acetatis  vel  atropise  sulphatis,  aa  gr.  x  ; 

Creasoti,  q.  s. 
S. — A  thick  paste  to  be  made. 

The  length  of  time  that  arsenic  should  be  allowed  to  remain  in  a 
tooth  will  be  found  to  depend  upon  the  structure  of  the  organ  and 
the  amount  of  the  material  that  has  been  used.  A  proper  amount 
would  be  just  that  quantity  necessary  to  accomplish  the  destruction 
of  the  pulp,  and  which  in  such  destruction  would  find  itself  antagon- 
ized. As  such  a  quantum  might  not,  however,  have  accurate  meas- 
urement, it  is  found  desirable  to  consider  rather  the  structure  of  the 


372  ORAL  DISEASES  AND   SURGERY. 

tooth ;  where  this  is  found  very  solid  and  close,  there  may  exist 
little  objection  to  allowing  the  preparation  to  take  care  of  itself. 
Where,  however,  such  structure  is  loose,  with  organic  matter  in 
excess, — a  condition  made  satisfactorily  evident  by  a  few  cuts  with 
an  excavator, — the  effect  of  an  application  is  to  be  watched  with  a 
judgment  which,  perhaps,  comes  only  of  experience.  A  period 
which  shall  approximate  a  rule,  however,  in  which  arsenic  may  be  left 
in  the  adult  tooth,  is  fifteen  hours;  although  nothing  is  more  common 
than  to  allow  it  to  remain  for  twenty-four.  The  danger  in  excess 
of  time  would  seem  to  lie  in  the  passage  of  the  agent  through  the 
foramen  and  tubuli,  affecting  thus  the  periodonteum. 

That  the  action  of  an  arsenical  application  on  a  pulp  in  a  tooth  of 
loose  structure  shall  be  as  direct  and  speedy  as  possible,  it  would 
seem  to  be  a  desirable  practice — where  the  touch  is  suflBciently  deli- 
cate to  accomplish  it  painlessly — freely  to  expose  the  organ  before 
making  the  application.  Such  exposure  effected,  the  paste  may  be 
at  once  pricked,  by  means  of  a  very  sharp-pointed  broach,  into  the 
organ.  By  such  an  operation  a  pulp  may  be  destroyed  almost 
without  pain,  particularly  if  atropia  be  previously  used  as  an  ob- 
tunder,  and  may  be  removed  from  its  cavity  within  a  period  of  time 
not  exceeding  fifteen  minutes. 

Recognition  of  the  death  of  a  pulp  is  found  in  the  absence  of  the 
previously-existing  sensibility,  as  made  manifest  by  the  touch  of  the 
exploring  instrument.    (See  Filling  Roots.) 

3.  A  Diseased  Slate  of  the  Periodonteum.  (See  Periodontitis 
and  Alveolar  Abscess.) 

4.  Confinement  of  Pus  and  Gas  in  the  Pulp  Cavity. — When 
the  dental  pulp  dies,  decomposition  is  likely  to  follow.  As  the 
result  of  such  lesion  we  have  two  sequences :  either  the  decomposed 
matter  is  gradually  absorbed  into  the  dentinal  tubuli,  and  thus  dis- 
posed of,  as  made  evident  in  the  marked  opacity  of  the  tooth,  or  it 
becomes  a  source  of  great  irritation  and  offense  to  the  surrounding 
healthy  structures.  Periodontitis  is  very  apt  to  be  provoked,  the 
evolution  of  gas  forcing  the  matter  unduly  into,  and  in  many  cases 
entirely  through,  the  foramen.  If  inflammation  of  the  alveolo-dental 
membrane  does  not  result,  then  the  trouble  induced  becomes  of  the 
ordinary  neuralgic  character.  The  living  nerve-filament  at  the  fora- 
men, still  more  or  less  associated  with  its  continuation  ramifying  in 
the  dead  pulp,  takes  on  inflammation,  and  thus  irritability  not  only  of 
these  special  filaments  results,  but  the  whole  trifacial  tract  is  apt  to 


THE   TEETH  AND    THEIR  DISEASES.  373 

sympathize.  Some  of  the  most  severe  and  unbearable  neuralgias  I 
have  ever  treated,  situated  about  the  various  parts  of  the  head,  have 
been  quickly  cured  by  discovering  and  treating  the  cause  in  a  confined 
dead  pulp.  I  just  now  recall  a  marked  example, — a  patient  of  the 
late  Dr.  Elisha  Townsend, — treated  by  me  for  that  gentleman  during 
the  sickness  which  destroyed  his  valuable  life.  The  patient  was  a 
professional  man,  and  had  been  completely  lost  to  all  self-control,  or 
reason,  for  a  period  of  three  days,  from  the  effect  of  neuralgic  pain 
running  between  the  orbit  and  the  dura  mater  of  the  anterior  portion 
of  the  cranial  cavity.  In  this  case  not  the  slightest  complaint  was 
made  of  any  of  the  teeth.  Examining  the  mouth,  however,  in  the 
search  for  a  cause,  I  discovered  a  half-carious  and  evidently  dead 
lower  bicuspid  tooth,  but  with  no  connection  between  the  cavity  of 
decay  and  the  pulp  cavity.  With  a  spear-shaped  drill  I  effected  this 
communication,  and  in  a  single  instant  the  patient  expressed  himself 
as  cured.  Relieved  of  the  pain,  he  fell  into  a  sound  sleep,  which 
continued  some  fifteen  hours ;  the  next  morning  he  went  about  his 
duties  as  usual. 

Any  portion  of  the  head,  throat,  or  associate  parts  supplied  by 
the  fifth  nerve,  or,  indeed,  by  its  related  nerves,  may  be  the  seat  of 
reflex  trouble  from  a  dead  pulp.  Thus  we  may  have  odonto-gas- 
tralgia,  odonto-cephalalgia,  odonto-cardialgia,  etc.  ;  even  sciatica  has 
been  cured  by  the  extraction  of  a  diseased  tooth. 

The  common  treatment  in  all  such  cases  is  to  remove  the  tooth, 
or  otherwise,  if  it  is  desirable  to  save  the  organ,  drill  an  opening 
into  the  pulp  cavity.  The  relief  experienced  is  generally  almost 
instantaneous. 

A  tooth  containing  a  dead  pulp  is  distinguished  by  its  loss  of 
translucency  when  compared  with  its  fellows,  or  in  an  opacity,  ex- 
hibited by  reflecting  upon  it,  by  means  of  a  hand-mirror,  the  rays 
of  the  sun. 

A  case  illustrative  of  practice  in  this  direction  finds  example  in 
a  patient  under  the  care  of  the  author  at  the  moment  of  writing 
this  paragraph.  Mrs.  H.,  a  lady  of  delicate  organization,  suffered 
for  a  whole  week  with  severe  pain  situated  in  the  alveolar  region 
overlying  the  superior  incisor  teeth, — the  teeth,  however,  seeming 
not  at  all  implicated.  In  the  beginning  of  the  second  week  the 
lady  first  presented  herself,  directing  attention  to  an  elongation  of 
the  right  central  tooth,  but  which  elongation,  according  to  the 
statement  of  the  mother,  had  always  existed.  Examination  of  the 
mouth    exhibited   not   the   slightest   discoloration  or  inflammation 


374  ORAL  DISEASES  AND   SURGERY. 

about  the  gums.  The  lateral  incisor,  however,  was  recognized 
to  be  very  slightly  loose, — this  and  the  continuous  pain  being  the 
only  expressions  of  a  pathological  condition.  Diagnosing  the  exist- 
ence of  a  dead  pulp  in  this  tooth,  the  chamber  was  entered  by 
means  of  a  spear  drill  applied  to  the  palatine  face  ;  on  opening  the 
cavity  at  least  a  teaspoonful  of  pus  escaped  into  the  mouth.  A 
treatment  pursued,  which  has  so  nearly  eventuated  in  a  cure  that 
the  patient  will  be  dismissed  on  her  next  visit,  is  as  follows:  The 
quantity  of  pus  demonstrating  the  existence  of  a  reservoir  outside 
the  tooth,  an  incision  was  made  through  the  gum  at  the  apex  of 
the  root,  exposing  the  bone.  To  this  bone  was  next  applied  the 
point  of  a  strong  bistoury,  which  being  pressed  forward  was  felt  to 
pass  through  a  shell  of  bone  and  enter  a  cavity ;  out  of  this  cavity 
issued  a  second  volume  of  pus.  Examination  of  the  cyst  exhibited 
it  as  capable  of  accommodating  all  the  fluid  that  had  escaped,  while, 
furthermore,  absorption  was  seen  to  be  progressing  towards  the 
right  naris,  into  which,  without  doubt,  sooner  or  later,  the  abscess 
would  have  discharged  itself.  The  cavity,  after  being  washed  out, 
was  injected  with  the  ordinary  officinal  tincture  of  iodine,  a  tent  of 
cotton  being  inserted  to  keep  the  opening  in  the  soft  parts  patulous. 
On  the  third  day  the  pulp  canal  of  the  tooth  was  filled  with  gold 
to  its  apex,  great  care  being  taken  that  no  portion  of  the  metal 
should  be  thrust  through  the  foramen,  which  foramen,  without  doubt, 
was  enlarged.  Up  to  the  present  hour — two  weeks  having  passed — 
the  cyst  has  been  daily  injected  with  the  iodine  solution  ;  and  the 
cavity  has  been  daily  growing  smaller,  until  it  is  now  so  nearly 
obliterated  that  it  may  be  left  to  take  care  of  itself. 

The  inflammation  in  this  particular  case  was  decidedly  of  a  cold 
or  chronic  character.  Had  it  been  acute,  the  tooth  would  have  been 
found  too  painful  to  fill  with  so  short  a  period  intervening  between  the 
time  of  attack  and  operation.  One  sinus,  however,  is  always  enough 
in  an  alveolar  abscess ;  if  it  exists  in  the  gum  there  can  be  no  objection 
to  filling  the  tooth  so  soon  as  the  sensibility  of  the  organ  may  admit. 

The  splitting  of  teeth  from  expansion  of  gas  confined  in  a  pulp 
cavity  seems  a  matter  of  record  too  authentic  to  be  doubted.  A  case 
having  peculiar  interest  in  such  direction,  published  by  Dr.  J.  H. 
M'Quillen,  is  to  be  found  on  the  pages  of  the  Dental  Cosmos, 
vol.  xiii. 

5.  Granules  of  Osteo-dentine  in  the  Pulp. — In  rare  cases  there 
is  found  to  exist  an  irritability  of  the  dental  pulp  which  exhausts 


THE   TEETH  AND    THEIR    DISEASES.  375 

itself  in  the  foi-mation  of  isolated  granules  of  semi-bonelike  char- 
acter, which  obtain  lodgment  in  some  portion  of  the  organ,  and 
become,  in  turn,  the  source  of  gi'eat  offense  to  the  parts,  result- 
ing indeed  frequently  in  an  odontalgia  than  which  there  are  few 
severer  forms.  To  diagnose  this  condition  is  an  exceedingly  diffi- 
cult matter,  and  it  can,  perhaps,  be  best  done  by  exclusion.  The 
teeth  in  these  cases  present  every  appearance  of  the  highest  health : 
no  discoloration,  no  soreness  on  pressure,  and  not  unfrequently  being 
without  the  slightest  local  pain  ;  this  manifestation  being  situated 
in  some  distant  part,  as  the  ear,  the  eye,  the  scalp,  etc.  Whether, 
however,  the  pain  may  be  localized  or  diffused,  it  is  always  ex- 
pressed by  the  patient  as  being  entirely  unbearable,  and  is  commonly 
more  or  less  paroxysmal  in  character,  thus  being  mistaken  for  idio- 
pathic neuralgia,  and  frequently  so  treated.  A  case  illustrative  just 
comes  to  my  mind.  During  a  late  session  of  the  University  of  Penn- 
sylvania, a  student  in  the  medical  department  applied  to  me,  suf- 
fering from  neuralgia,  so  severe  as  to  have  entirely  incapacitated 
him  for  study  for  a  period  of  some  three  weeks.  During  this  time 
he  had  tried  all  the  ordinary  remedies  which  had  suggested  them- 
selves, without  finding  the  slightest  relief.  The  pain  varied  between 
the  tuberosity  of  the  superior  maxilla  and  the  ear.  The  teeth,  about 
the  tuberosity,  were  as  sound  and  as  healthy-looking  as  any  I  have 
ever  seen;  there  was  apparently  no  local  lesion;  while,  on  the  other 
hand,  the  physique  of  the  gentleman  was  not  at  all  of  the  neuralgic 
type.  I  was  perfectly  at  sea  with  the  case,  until,  after  a  day  or 
two,  there  came  to  my  mind  an  instance  of  innodular  calcification  of 
the  dental  pulp  I  had  once  seen,  where  the  patient  had  suffered  in 
about  a  like  manner.  Now,  I  was  not  prepared  positively  to  affirm 
that  here  was  a  second  case  of  calcification;  but  so  well  satisfied 
was  I  of  the  existence  of  such  a  condition  that  I  requested  and 
obtained  the  consent  of  the  gentleman  that  I  should  pass  an 
exploratory  drill  into  the  pulp  cavity  of  the  wisdom  tooth.  The 
result  was  the  finding  of  the  pulp  filled  with  granules — granules 
of  secondary  dentine,  as  they  are  technically  termed.  The  extrac- 
tion of  the  tooth  was  followed  by  the  immediate  cessation  of  all 
pain,  and  the  patient  was  able  to  go  from  my  office  direct  to 
lectures. 

A  marked  case,  where  the  lesion  gives  direct  local  manifestation, 
the  pain  being  seated  directly  in  the  affected  tooth,  exists  in  the 
person  of  a  professional  friend.  The  gentleman  may  be  said  to  be 
affected  with  a  diathesis  in  this  direction.     More   beautiful   teeth 


376  ORAL  DISEASES  AND   SURGERY. 

than  he  possesses,  or,  rather,  did  possess,  I  have  never  seen ;  and 
yet,  one  by  one,  they  take  on  this  condition,  exciting  such  madden- 
ing pain  that,  regardless  of  everything,  he  flies  to  extraction  for 
relief.  In  this  way,  within  the  past  few  years,  he  has  lost  all  his 
upper  teeth. 

The  treatment  of  this  form  of  odontalgia  consists  in  drilling  into 
the  body  of  the  aifected  tooth,  and  securing  thus  a  cavity  of  reten- 
tion ;  apply  the  arsenious  paste  as  has  been  directed.  There  are, 
however,  cases  in  which,  under  these  circumstances,  it  seems  im- 
possible to  effect  the  destruction  of  the  organ.  Here  there  is  nothing 
to  be  done  but  to  extract  the  tooth  or  teeth. 

The  subject  of  the  changes  which  may  take  place  in  the  dental 
pulp,  being  the  result  either  of  age  or  other  circumstances,  com- 
mands, necessarily,  the  attention  of  the  surgeon.  "Much  as  physi- 
ologists differ  with  regard  to  the  precise  method  of  dentificatiou,"  says 
Mr.  R.  T.  Hulme,  M.R.C.S.,  in  an  admirable  paper  "  On  the  Calci- 
fication of  the  Dental  Pulp,"  "yet  all  are  agreed  that  it  takes  place 
through  the  agency  of  the  pulp,  and  that,  commencing  on  the  apex 
and  external  surface  of  the  formative  organ,  it  then  proceeds  inward 
until  the  tooth  acquires  its  prescribed  form  and  size,  and  the  dentine 
has  attained  its  normal  thickness.  When  this  is  accomplished,  the 
formation  of  the  tooth  is  completed,  and  the  same  arrest  of  growth 
takes  place  as  occurs  in  every  other  part  of  the  body  at  the  adult 
period  of  life.  If  the  person  enjoys  good  health,  and  the  tooth 
remains  free  from  injury  or  disease,  it  may  continue  for  some  years 
without  any  appreciable  alteration,  in  either  the  osseous  tissues 
which  enter  into  its  formation,  or  in  the  pulp  itself.  Sooner  or  later, 
however,  as  years  go  on,  a  change  takes  place  in  the  character  of 
the  nutritive  process  throughout  the  body.  The  proportion  which 
the  fluids  bore  to  the  solids  in  early  or  middle  life  is  diminished, 
nutrition  is  accomplished  more  slowly,  and  the  composition  of  the 
various  tissues  undergoes  a  marked  alteration.  There  is  a  general 
induration  of  the  parts,  and  a  tendency  to  the  deposition  of  ossific 
matter:  ligament  is  converted  into  cartilage,  cartilage  into  bone, 
the  coats  of  the  blood-vessels  are  often  impregnated  with  calcareous 
matter,  and  the  cartilage  of  the  ribs  becomes  ossified.  If  we  turn 
our  attention  to  the  teeth,  or,  more  correctly  speaking,  to  their  pulps, 
we  shall  find  that  they  also  are  liable  to  a  similar  alteration  of 
structure.  When  a  section  is  made  through  an  old  tooth,  apart 
from  the  changes  which  may  be  noticed  in  the  color  and  transparency 
of  certain  portions  of  the  original  dentine,  the  pulp  cavity  will  be 


THE   TEETH  AND    THEIR  DISEASES.  377 

seen  to  have  been  greatly  encroached  upon,  and  the  entire  mass  of 

the  tooth  increased  in  thickness.     The  extent  to 

which  this  filling-up  of  the  pulp  cavity  can  take     Fig.  123.  Fig.  124. 

place  is  shown  in  the  accompanying  drawings. 

Fig.  123  represents  a  section  of  a  fully-developed 

molar  in  early  life,  when  the  tooth  has  attained 

its  normal    amount   of   growth;    while  Fig.  124 

represents  a   similar    section   of  a   molar   tooth 

taken  from  an  elderly  person,  and  in  which  the 

pulp  cavity  has  become  diminished  to  the  extent  of  fully  one-half  of 

its  original  dimensions.     This  change  in  the  cavity  of  the  tooth  can 

only  have  taken  place  through  the  agency  of  the  pulp,  which,  after 

a  period  of  repose,  must  have  returned  to  its  original  function  of 

calcification,  and  have  added  fresh  layers  of  dentine  to  the  inner 

surface  of  the  tooth. 

"  '  The  teeth,'  says  Wedl,  '  are  distinguished  at  different  ages  by 
a  diminution  of  the  pulp  cavity,  an  increase  of  thickness  in  the 
cementum,  and  a  lessening  of  that  of  the  enamel,  and  of  the  trans- 
parency of  the  three  dental  substances  ;  by  the  edges  and  angles 
becoming  blunted,  and  the  surface  assuming  a  yellow  tinge,  etc. 
These  distinctions  are  most  striking  in  the  teeth  of  old  men.  In 
the  pulp  of  teeth  in  this  condition  will  be  noticed  a  considerable 
diminution  in  the  quantity  of  blood,  the  color  of  that  tissue  often 
passing  into  a  brownish  yellow,  from  the  quantity  of  pigment  de- 
posited in  it.  Earthy  salts,  assuming  the  outward  form  of  the 
botryoidal  corpuscles  met  with  in  the  pineal  gland,  occur  on  the 
inner  surface  of  the  pulp  cavity  and  of  the  dental  canal,  and  also 
deposited  in  groups  in  the  substance  of  the  pulp.  An  increased 
number  of  layers  of  cementum  will  be  observed,  though  these  are 
often  concealed  by  the  opaque,  brownish-yellow  color  of  the  inter- 
corpuscular  substance.  In  thin  sections,  the  dentine,  sometimes 
throughout,  sometimes  only  in  isolated  spots,  appears  less  trans- 
parent than  natural,  and  the  dentinal  tubes  become  less  distinct, 
and  occasionally  disappear  in  the  dark-gray  or  brownish-yellow 
substance.  These  partial  opacities  of  the  dentine  are  manifested, 
even  to  the  naked  eye,  by  a  speckled  appearance.  The  enamel 
presents  dark,  reddish -brown  spots,  and,  as  well  as  the  dentine, 
appears  to  have  lost  some  of  its  elasticity,  and  to  have  become  more 
brittle.'" 

Teeth  subjected  to  sources  of  local  irritation  are  frequently — indeed, 
it  is  rather  to  be  said,  are  commonly — found  responsive  in   the  way 


378 


ORAL  DISEASES  AND  SURGERY. 


Fig.  125. 


of  self-atteniptiug  deposits.  This  subject  has  been  discussed  in  con- 
nection with  filling  and  filing  teeth.  In  Fig.  125 
is  exhibited  a  tooth  which,  as  may  be  seen,  has 
been  worn  into  a  groove  at  the  neck;  in  the  pulp 
cavity,  antagonizing  the  groove,  is  seen  a  deposit 
of  secondary  dentine. 

The  re-forniative  efforts  of  the  dental  pulp  dif- 
fer from  conditions  as  shown  in  the  diagrams  to 
the  complete  conversion  of  its  substance  into  a 
species  of  dentine,  so  that  it  is  often  found,  on 
cutting  open  a  tooth  long  subjected  to  irritating 
influences,  that  the  cavity  commonly  existing  is 
occupied  by  solid  matter. 

A  form  of  secondary  dentine  occasionally  met 
with  is  shown  in  Fig.  126.  This  diagram  repre- 
sents a  specimen  met  with  by  Mr.  S.  J.  Salter, 
and  by  him  presented  to  the  attention  of  the 
Pathological  Society  of  London.  In  this  case, 
as  is  seen,  the  mass  is  attached  to  the  chamber 
wall  of  the  tooth. 

"The  tooth,  as  mentioned  in  Mr.  Hulme's 
paper,  was  a.  central  incisor  which  had  been 
extracted  from  a  woman  on  account  of  severe 
neuralgic  pains,  obviously  connected  with  one  of 
the  central  incisors  of  the  up|)er  jaw.  The  pain  was  described  as 
of  a  gnawing  character,  abiding,  but  not  constantly  severe ;  frequently 
amounting  to  a  mere  consciousness  of  the  presence  of  the  tooth,  and 
at  other  times  sharp  and  darting.  In  the  former  condition  it  was 
confined  to  the  region  of  the  tooth;  in  the  latter,  it  flashed  up  the 
side  of  the  face,  and  through  all  the  branches  of  the  superior  max- 
illary division  of  the  fifth  nerve  of  that  side.  Sudden  pressure  or 
a  tap  upon  the  tooth,  or  a  marked  change  of  temperature,  produced 
a  considerable  augmentation  of  pain.  The  tooth  itself  was  sound, 
to  all  external  appearance  ;  it  was  somewhat  elongated  beyond  its 
fellow,  and  was  very  slightly  loose.  The  gum  surrounding  it  was 
red  at  the  edge,  and  a  little  swollen.  When  the  tooth  was  removed, 
no  exostosis  was  discovered  on  it;  and,  with  the  exception  of  some 
small  patches  of  half-organized  lymph,  it  appeared  quite  healthy. 

"Upon  making  a  vertical  section  of  the  tooth  from  side  to  side, 
an  oval  pear-like  excrescence  of  dentine  was  found  growing  from 
the  side  of  the  pulp  cavity,  so  as  to  encroach   much  upon  it,  and 


THE   TEETH  AND    THEIR   DISEASES. 


379 


occupying  for  a  short  space  more  than  half  its  diameter.  It  was  of 
an  oval  form,  its  long  axis  corresponding  to  that  of  the  tooth ;  in 
color  less  opaque,  and  yellower  than  the  neighboring  tissue. 


Fig.  126. 


Fig.  127. 


\ 


"  The  structure  was  of  that  irregular  character  which  has  been 
previously  described  as  occurring  in  secondary  dentine,  which  has 
arisen  from  the  wearing  away  of  some  part  of  the  tooth's  surface. 
The  removal  of  the  tooth  was  accompanied  with  a  violent  paroxysm 
of  neuralgic  agony,  but  was  followed  by  a  total  cessation  of  pain, 
and  the  cure  was  permanent  " 

Masses  of  dentine — nodular  dentine,  as  it  has  been  named  by  Mr. 
Salter — occupying  positions  in  the  substance  of  the  pulp,  are  to  be 
met  with  as  among  the  causes  of  odonto-neuralgia,  as  alluded  to  on  a 
former  page.  These  nodules  may  be  single  or  multiform  ;  the  author 
has  in  his  possession  specimens  in  which  at  least  a  dozen  are  to  be 
found  in  the  same  pulp.  These  nodules  differ  markedly  in  form. 
Dr.  J.  F.  Flagg,  whose  curiosity  has  prompted  him  to  the  preserva- 
tion of  a  large  number  of  specimens,  makes  an  interesting  classi- 
fication. 

Taking  advantage  of  a  cut  at  command  (Fig.  127),  a  specimen  is 
shown  from  the  collection  of  Mr.  Hulme,  and  which  is  thus  described 
by  that  gentleman  : 

"Examination  of  the  Tooth. — The  decay  extended  to  the  pulp 
cavity,  and  the  median  third  of  the  crown  was  more  or  less  affected 
by  caries.  The  tooth  was  then  broken  open  and  the  pulp  examined. 
It  was  of  a  pinkish  color,  and  somewhat  more  vascular  than  usual. 
On  endeavoring  to  withdraw  the  pulp  from  the  cavity,  at  the  part 


380  ORAL  DISEASES  AND  SURGERY. 

which  was  directly  under  the  carious  portion  there  was  found  a  solid 
lump  of  osseous  matter  as  large  as  a  canary-seed,  and  something 
less  than  a  grain  in  weight;  it  was  not  adherent  to  any  part  of  the 
inner  wall  of  the  tooth.  On  examining  the  remainder  of  the  pulp 
beneath  the  microscope  after  the  addition  of  a  solution  of  caustic 
soda,  it  was  seen  to  be  thickly  crowded  with  rounded  masses  of  den- 
tine, but  more  opaque  and  of  a  different  character  to  the  dentine 
globules  of  Czermac.  The  drawing  represents  the  appearance  pre- 
sented by  this  portion  of  the  pulp." 

No  form  of  odonto-neuralgia  is  more  severe  and  persistent  than 
this  arising  from  pulp  calcification.  In  this  direction  it  has  happened 
to  the  author  since  his  connection  with  the  University  Hospital  to 
gee  among  the  clinic  patients  quite  a  number  of  cases.  The  diagno- 
sis is  perhaps  always  a  matter  of  difficulty,  and  at  times  only  satis- 
factorily to  be  settled  by  the  extraction  of  teeth  presenting  more  or 
less  evidence  of  complication.   (See  Neuralgia) 

6.  Sympathy. — Sympathetic  toothache  is  most  frequently  found 
to  be  associated  with  teeth  having  a  common  period  of  eruption. 
Thus,  if  attention  is  called  to  an  aching  bicuspis,  and  examination 
discovers  it  to  be  in  healthy  condition,  w'e  will  commonly  find  the 
primary  lesion  in  either  of  the  three  fellow-teeth.  If  it  is  the  first 
or  third  molar,  or  any  particular  tooth,  that  may  seem  to  be  aching, 
the  real  seat  of  pain  may  be  found  in  the  associate  organs.  This  is 
the  first  and  most  common  relation  of  sympathy.  Other  and  in- 
direct causes  exist  in  various  directions,  the  most  constant  of  such 
associations  being,  first,  with  the  ear,  second,  with  the  uterus. 

That  odonto-otalgia,  cephalalgia,  gastralgia,. — indeed,  any  reflex  or 
radiated  pain  having  origin  in  the  teeth,  but  expressing  its  manifes- 
tation in  distant  organs,  and  vice  versa, — may  exist,  is  at  once  to  be 
appreciated  in  a  recollection  of  anatomical  associations;  instances 
abundant  are  on  record  illustrative  of  such  relationship.  Thus,  as 
an  example,  allusion  may  be  made  to  a  case  reported  by  J.  L.  Sues- 
serott,  M.D.,  of  Chambersburg.  "The  patient,  Mr.  J.  G.,  an  old  man 
seventy  years  of  age,  applied  to  me,"  says  Dr.  S.,  "  with  the  hope 
of  being  relieved  of  an  intensely  painful  tic  douloureux  through  the 
extraction  of  two  or  three  fragments  of  roots  of  the  superior  incisor 
teeth,  all  the  other  teeth  and  roots  of  the  upper  jaw  having  been 
long  before  extracted." 

The  suffering  of  the  patient  at  the  time  of  this  first  visit  is  de- 
scribed as  of  an  extreme  character,  "a  breath  of  air,  the  slamming 


THE  TEETH  AND    THEIR   DISEASES.  381 

of  a  door,  or  even  an  allusion  to  bis  disease,  being  sufficient  to  pro- 
duce a  violent  paroxysm.  Tbe  irritation,  although  reflected,  as  it 
afterward  proved  to  be,  appeared  confined  principally  to  the  superior 
and  middle  branches  of  the  par  trigeminum  of  the  left  side.  This 
suffering  had  been  so  intense  and  long-continued  that  there  was 
considerable  swelling  and  tenderness  upon  pressure  along  the  course 
of  all  the  ramifications  of  the  fifth  pair. 

"  Feelingthe  case,"  continues  the  description,  "  to  be  a  desperate  one, 
although  not  sdspecting  the  causa  morbi,  I  determined  on  an  active 
and  energetic  course  of  treatment.  Directing  my  efforts  to  the 
removal  of  the  existing  irritation,  and  I  might  also  say  inflammation, 
I  established  an  issue  on  tbe  back  of  the  neck,  which,  together  with 
blisters  to  his  temples,  produced  a  considerable  amount  of  counter- 
irritation.  The  external  use  of  aconitine,  and  the  internal  adminis- 
tration of  the  citrate  of  iron  and  quinine  in  full  doses,  produced  a 
marked  alleviation ;  but  just  at  the  time  when  hope  was  the  brightest, 
another  severe  paroxysm  would  fill  us  with  disappointment,  and 
almost  compel  us  to  declare  that  there  is  no  virtue  in  medicine. 

"A  period  of  two  weeks  having  been  uselessly  expended,  together 
with  no  small  amount  of  medicine  and  patience,  the  patient,  as  I 
was  dressing  his  issue,  happened  to  remark  that  '  his  stomach  was 
not  in  fault,  for  that  he  could  digest  without  discomfort  pieces  of 
meat  as  large  as  he  could  swallow.''  Those  who  have  anxiously 
watched  over  an  interesting  and  difficult  case  can  enter  into  my 
feelings  of  gratulation,  for,  like  Archimedes,  I  felt  I  might  exclaim, 
Eureka  !  Remembering  the  old  maxim,  tolle  causam,  cessat  effectus, 
I  directed  my  efforts  to  the  improvement  of  the  patient's  manner  of 
mastication  and  to  the  directing  of  a  proper  character  of  food,  with 
the  result  of  a  speedy  cure  of  his  trouble." 

As  an  example  of  reflection  in  an  opposite  direction,  a  case  may 
be  cited  from  an  interesting  and  valuable  paper  read  by  Julius 
Chesebrough,  D.D.S.,  before  the  American  Dental  Association. 

"I  have  seen,"  says  this  gentleman,  "a  case  wherein  a  fine- 
formed  young  woman  suffered  for  a  year  after  the  birth  of  her  child 
with  pain  in  her  teeth,  alternately  with  that  of  the  uterus.  This 
case  was  one  that  had  perplexed  the  physician  in  charge,  and  was 
presented  to  the  medical  society  for  advice.  Being  called  on,  and  a 
statement  of  the  case  made  to  me,  I  at  once  suggested  that  the 
uterine  derangement  came  from  the  teeth,  and  that  these  organs  were 
the  only  morbid  ones.  There  was  some  doubt  expressed  as  to  this 
being  a  correct  diagnosis  of  the  case,  for  she  had  no  toothache  before 


382  ORAL  DISEASES  AND   SURGERY. 

her  labor,  and  the  pain  in  her  teeth  was  since  that  event.  Suggest- 
ing that  examination  be  made  of  the  teeth,  a  visit  was  paid  the 
patient,  with  the  result  of  finding  decay  in  the  four  wisdom-teeth. 
Three  of  these  were  extracted  without  giving  much  pain,  but  while 
extracting  the  fourth — the  left  superior — it  seemed  as  if  the  woman 
was  contracting  within  herself,  and  suffered  intensely  from  uterine 
pain.  After  half  an  hour,  however,  her  pain  ceased,  and  she  was 
entirely  free." 

A  case  even  more  directly  the  opposite  of  the  first  example  is 
mentioned  in  this  same  paper,  in  which  a  patient  suffering  from 
continual  pain  in  the  stomach  was  only  cured  upon  the  accidental 
treatment  of  a  carious  tooth, — the  pain  in  the  stomach  ceasing  imme- 
diately upon  the  application  of  arsenical  paste  to  an  exposed  pulp, 
A  second  time  the  same  patient  is  reported  as  presenting  himself, — 
the  pain,  which  was  of  similar  character  and  location  as  in  the  first 
instance,  finding  again  immediate  cure  in  the  treatment  of  a  second 
diseased  tooth.     In  neither  instance  was  pain  noticed  in  the  teeth. 

Of  the  various  viscera,  cases  illustrative  might  be  given  of  odon- 
talgic association,  while  pains  outside  the  splanchnic  cavities,  as  in 
the  hip-joint,  etc.,  have  found  relief  not  unfrequently  only  in  attention 
directed  to  the  teeth.  In  the  chapter  on  neuralgia  the  reader  will 
find  the  subject  abundantly  illustrated. 

To  understand  the  subject  of  the  radiation  or  reflection  of  pain, 
consideration  is  to  be  given  to  the  anatomical  associations  of  the 
nervous  system.  This  considers  the  cerebro-spiual  and  ganglionic 
systems,  and  refers  the  reader  to  his  text-books  on  anatomy  and 
physiology. 

7.  Recession  and  Absorption  of  the  Gum  and  Alveolus. — When, 
for  any  reason,  the  gum  falls  below  the  enamel  cap,  the  periodon- 
teum  and  cementum  become  exposed  to  various  sources  of  irrita- 
tion. The  odontalgia  thus  provoked  is  seldom,  however,  acute 
or  severe  in  its  character,  but  dull  and  annoying.  The  practice  in 
these  cases  is  generally  most  unsatisfactory,  resulting,  sooner  or 
later,  in  the  necessity  for  extraction.  If  the  recession  is  associated 
with  acute  conditions  or  with  the  presence  of  agents  of  offense, 
treatment  directed  to  meet  the  indications  may  result  very  well ; 
but  commonly  such  recession  is  slow  and  chronic,  and  admits  of  no 
remedy.  Medicaments  to  neutralize  or  correct  irritative  conditions 
in  the  oral  fluid  are  sometimes  demanded,  and  answer  a  very  good 
end.     Of  such  neutralizing  agents,  acids  or  antacids  are  employed, 


THE    TEETH  AND    THEIR   DISEASES.  383 

according  to  the  indications  yielded  to  the  test  papers.  I  myself 
generally  use  lime-water  in  the  one  direction,  and  very  dilute  citric 
acid  in  the  other. 

A  treatment  for  absorption  of  the  alveolus  suggested  by  Dr. 
Riggs,  of  New  York,  consists  in  scraping  the  absorbing  bone,  pre- 
cisely as  is  done  in  osseous  caries.  This  is  to  be  accomplished 
without  difiBculty  by  introducing  between  the  neck  of  the  tooth  and 
gum  the  common  lathe-shaped  excavator,  which,  upon  reaching  the 
alveolus,  is  made  to  cut  away  the  surface  surrounding  the  tooth. 
Dr.  Riggs  recommends  instruments  especially  prepared  for  the 
purpose,  but  any  instrument  which  is  capable  of  meeting  the  indica- 
tion answers  the  purpose  of  the  suggestion.  Such  an  operation 
has,  in  theory,  much  to  commend  it;  in  practice,  however,  the 
author  has  not  found  himself  able  to  get  from  it  the  benefit  claimed 
to  have  accrued  in  the  practice  of  the  gentleman  devising  it. 

A  character  of  recession  of  the  gums  from  about  the  necks  of  the 
teeth,  or,  to  express  it  better,  a  condition  in  which  the  teeth  are 
raised  in  their  sockets,  and  where  a  cure  is  impossible,  is  found  as 
the  result  of  a  growing  density  in  the  structure,  in  which  the 
equilibrium  of  circulation  between  these  organs  and  surrounding 
parts  becomes  so  deranged  that  they  are  as  foreign  bodies,  and 
the  recession  really  implies  a  filling-up  of  the  alveoli  by  an  osseous 
deposit  with  the  object  of  their  removal.  In  these  cases  the  teeth 
will  seldom  be  seen  affected  by  caries,  being  dense  to  an  extent 
which  is  cognizable  to  the  naked  eye. 

Recession  arising  from  the  employment  of  non-soluble  dentifrices 
is  frequently  to  be  met  with.  Such  condition  is  to  be  recognized  from 
the  history  of  the  case,  from  the  presence  of  particles  of  the  sub- 
stance of  offense,  and  from  the  disease  seeming  to  implicate  the  gum 
alone.  Such  cases  have  their  cure  in  withdrawal  from  use  of  the 
injurious  agent,  in  the  free  syringing  of  the  part  with  a  medicated 
water, — stimulation  being  required, — and  in  effecting  the  contraction 
of  the  turgid  gums  by  free  bleeding  secured  through  occasional  scari- 
fication. 


CHAPTER    XV. 

THE   TEETH   AND   THEIR   DISEASES. 

PILLING  THE  PULP  CHAMBER  AND  CANALS. 

The  pulp  of  a  tooth  dead,  and  the  intention  being  to  save  the 
organ,  appreciation  is  now  to  be  had  of  the  means  tending  to  such 
end.  It  is,  indeed,  within  the  memory  of  the  present  generation 
when  a  dead  pulp  was  considered  synonymous  with  the  loss  of  a 
tooth.  Now,  however,  it  has  come,  happily,  to  be  recognized  that 
such  attendant  loss  is  the  exception, — observation  eliciting  the  fact 
that  the  almost  universally  associated  destructive  sequelae  depended 
on  the  presence  of  the  putrid  mass  in  the  cavity  rather  than  on  the 
fact  of  death  of  the  pulp. 

With  such  understanding,  the  first  step  in  the  treatment  of  the 
pulp  chamber  and  canal  is  seen  to  consist  in  the  most  thorough 
cleansing  of  them  from  substance  which  has  become  foreign. 

To  remove  a  dead  pulp,  the  operator  commences  by  creating  an 
opening  into  the  chamber,  or  in  enlarging  to  convenient  size  one 
that  may  already  exist;  this  accomplished,  it  is  not  unfrequently 
the  case  that  the  pulp  may  be  caught  and  lifted  away  with  a  pair 
of  delicate  finger-forceps  A  more  common  mode  of  procedure, 
however,  consists  in  the  employment  of  a  barbed  broach ;  this  instru- 
ment being  passed  into  the  canal,  and,  when  rotated,  catching  and 
twisting  into  its  teeth  the  pulp,  its  withdrawal  brings  with  it  neces- 
sarily the  structure.  Fig.  128  represents  a  barbed  broach,  a  variety 
of  blades  being  shown  adapted  to  a  common  handle. 

In  attempting  to  remove  a  pulp  entirely  dead,  it  is  occasionally 
found  that  considerable  pain  attends  the  operation.  This  pain  will 
be  found  to  depend  on  the  manipulations.  A  broach  thrust  directly 
upon  a  dead  pulp  will  carry  necessarily  the  impression  to  the  living 
structure  still  in  relation  at  the  foramen  of  the  canal.  A  proper 
plan  is  to  enlarge  the  opening  to  such  extent  as  shall  allow  the 
introduction  of  the  instrument  between  the  wall  of  the  canal  and  the 
pulp.  Delicately  insinuated  in  this  manner,  and  the  rotation  com- 
(384) 


Fig.  128. 


THE   TEETH  AND    THEIR   DISEASES. 
Fig.  129. — Nerve  Extractors. 

^Driiwn  Ti'iiiiKT.— ,       , Spring  Tfinpcr. 


385 


12345  G78 

niencing  only  when  the  instrument  has  reached  the  bottom 
of  the  canal,  a  pulp  may  commonly  be  removed  without  a 
particle  of  discomfort. 

In  teeth  having  more  than  one  root,  it  is  generally  found 
necessary  first  to  remove  the  pulp  of  the  chamber  proper. 
This  may  be  effected  through  the  use  of  a  common  ex- 
cavator, simply  cutting  it  away ;  the  continuations,  occupy- 
ing the  canals,  are  now  to  be  removed,  as  described,  by  the 
use  of  the  broach. 

An  indication  following  immediately  the  removal  of  a 
dead  pulp  consists  in  such  sealing  of  the  emptied  chamber 
and  canals  as  shall  prevent  occupancy  by  foreign  matter, 
whether  from  within  or  from  without.  This  embraces  the 
processes  of  preparation  and  filling, — a  subject  to  which 
attention  may  now  be  directed. 

Taking  as  a  first  example  a  tooth  from  which,  after  the 
arsenical  application,  the  devitalized  pulp  has  just  been 
removed,  the  operator  is  to  consider  that  the  surface  of 
separation  at  the  foramen  of  the  tooth  cures  itself  either 
by  the  process  of  what  might  be  called  an  immediate 
cicatrization,  or  by  granulative  effort,  attended  with  more 
or  less  degeneration  of  plasma  and  discharge.  Could 
assurance  be  entertained  of  the  first  result,  then  no  better 
practice  might  be  pursued  than  the  immediate  introduc- 
tion of  a  permanent  filling.  As  this  may  not,  however, 
tractor,  wUh  ^®  the  casc,  what  is  termed  a  test  stopping  is  to  be  used. 

holder.  25 


386  ORAL  DISEASES  AND  SURGERY. 

Disinfecting  thoroughly  the  canal,  or  canals,  as  the  tooth  may  be  of 
a  single  root  or  of  several  roots,  using  for  such  purpose  plain  water 
thrown  forcibly  into  the  cavities  by  means  of  a  tooth-syringe, 
the  test  is  to  be  made  by  preparing  a  most  delicate  twist  of  cotton, 
which  in  length  may  double  that  of  the  tooth.  This  twist,  being 
moistened  in  a  weak  dilution  of  creasote,  in  phenate  of  soda,  oil  of 
cloves,  or  in  the  glycerole  of  thymol, — as  now  preferred  by  many, — 
is  to  be  taken  up  with  the  point  of  a  delicate  root-plugger,  and, 
being  carried  as  deeply  into  the  root  as  possible,  fold  after  fold  is 
to  be  forced  upon  it  until  the  space  is  solidly  packed.  The  canal 
thus  plugged,  the  chamber  proper  of  the  pulp  and  the  common 
cavity  of  decay  are  to  be  filled  either  with  white  wax,  with  gutta- 
percha, or,  what  is  found  to  answer  most  satisfactorily,  a  tuft  of 
cotton  which  has  been  partly  saturated  with  gum  sandarac. 

A  manner  of  filling  canals  temporarily,  which  will  be  felt  to  com- 
mend itself,  consists  in  employing  threads  of  the  ordinary  gilling 
twine.  The  canal  being  cleansed,  the  thread,  holding  the  antiseptic, 
is  carried  into  the  cavity,  and  packed  precisely  in  the  same  way  as 
the  cotton ;  an  end  of  the  thread  is,  however,  to  be  allowed  to  extend 
to  the  orifice  of  the  conmion  crown  cavity,  that  thus  the  packing 
may  be  most  easily  extracted  when  required. 

The  length  of  time  which  a  test  filling  is  to  be  allowed  to  remain 
varies  with  almost  every  case.  As  a  direction  which  may  serve  for 
a  principle,  it  may  be  said  that  when,  after  a  single  day,  a  closed 
cavity  remains  perfectly  comfortable, — the  patient  affected  by  no 
consciousness  of  the  presence  of  the  tooth, — and  when,  on  the  with- 
drawal of  the  test,  complete  cleanliness  is  to  be  recognized  in  the 
absence  of  offensive  odor,  such  a  pulp  cavity  may  be  esteemed  in 
condition  to  receive  the  permanent  filling.  Very  often,  however,  it 
is  seen  to  happen  that  a  test  filling  is  so  poorly  endured  that  its 
presence  for  a  single  half-hour  will  develop  symptoms  of  periodonteal 
irritability,  the  tooth  becoming  sore  to  the  touch  and  sensitive  to  all 
impressions.  Here  we  have  nothing  to  do  but  remove  the  test, 
applying  soothing  applications,  the  solution  of  the  atropiae  sulphas 
being  among  the  very  best  that  may  be  used.  The  cavity  is  now  to  be 
loosely  filled  with  cotton,  or  it  may  be  left  open,  and  allowed  to  rest 
until  the  irritability  has  subsided,  when,  a  few  days  or  a  week  having 
elapsed,  the  test  filling  may  be  again  tried. 

In  cases,  however,  where  in  single-rooted  teeth  resistance  is 
continuous,  it  is  implied  that  a  suppurating  surface  exists  on  the 
external  face  of  the  root,  and  that  the  discharge  or  oozing  finds  its 


THE    TEETH  AND    THEIR   DISEASES. 


387 


vent  through  the  canal.  In  these  cases,  while  the  operator  may,  if 
he  please,  try  stimulating  injections  forced  through  the  foramen, 
ti'usting  thus  to  find  himself  able  to  break  up  the  morbid  action,  a 
plan  which  will  be  practiced  with  much  more  satisfaction  consists 
in  the  immediate  permanent  filling  of  the  canal  with  gold,  and  the 
making  of  a  counter-opening  through  the  alveolus,  such  opening 
being  kept  patulous  by  the  use  of  a  tent  of  cotton.  No  better  plan 
of  treating  a  suppurating  periodonteum  may  be  adopted  than  using 
injections  through  a  counter-opening  as  thus  made. 

In  the  case  of  the  multi-rooted  teeth  resisting  the  test  filling,  trial 
is  to  be  made  until  the  particular  fang  diseased  is  discovered.  Such 
information  is  quickly  elicited  by  treating  each  canal  separately,  the 
diseased  one  alone  responding:  this  one  discovered,  it  is  to  be  filled, 
and  the  counter-opening  made  as  directed. 

Quiet  existing  in  a  pulpless  tooth,  the  filling  of  the  root  canal  is 
accomplished  as  follows.  Take  a  sheet  of  gold  (say,  for  illustration. 
No.  5) ;  cut  it  into  four  strips.  Take  one  of  these  strips,  and,  fold- 
ing it  once  upon  itself,  run  it  into  a  spiral  upon  a  broach  or  a  common 
pin.  Take  now  this  spiral,  and,  dipping  the  point  in  creasote,  carry 
it  by  means  of  a  foil-carrier  into  the  canal ;  if  it  has  been  solidly 
rolled,  it  may  be  forced  at  once  quite  to  the  apex  of  the  root. 
Following  the  carrier  with  a  root-plugger  (Fig.  130),  the  spiral  is  to 


Fig.  130. — Nerve-Canal   Pluggers. 


be  condensed  by  forcing  turn  into  turn,  spy-glass  fashion.  Of  the 
remaining  pieces,  cylinders  may  be  made  of  such  varying  sizes  as 
may  seem  required  for  the  operation. 

The  canal  proper  sealed,  the  pulp  chamber  is  to  be  filled  with  the 
oxychloride  of  zinc,  this  second  agent  being  interposed  as  a  non- 


388  ORAL   DISEASES  AND   SURG  ERF. 

conductor  between  the  filling  in  the  root  and  that  which  is  to  occupy 
the  cavity  in  the  crown. 

Another  metliod  of  using-  the  gold  consists  in  taking  a  strip  of 
heavy  foil  (say  No.  20),  and,  cutting  off  a  delicate  thread,  carrying  it 
by  a  point  to  the  apex  of  the  canal.  The  plugger,  fixing  thus  the 
initial  extremity,  is  to  be  slightly  withdrawn,  and  the  thread,  portion 
by  portion,  crimped  upon  itself  until  the  canal  is  full. 

Still  another  manner  of  treating  a  canal,  and  the  one  which  is 
perhaps  most  frequently  practiced,  consists  in  filling  first  the  apex 
of  the  canal  with  a  twist  of  cotton  which  has  been  impregnated  with 
creasote.  Upon  this  cotton  is  packed  the  gold,  as  directed*  In 
introducing  the  cotton,  it  is  only  necessary  to  make  a  twist,  the 
initial  extremity  of  which  shall  be  of  the  greatest  tenuity.  This 
initial  end,  or  as  near  it  as  may  be  possible,  is  caught  upon  the  end 
of  the  root-plugger,  and,  being  carried  to  the  apex  of  the  canal,  the 
remainder  of  the  twist  is  crimped  upon  it.  Operators  of  repute  are 
found  whose  commendation  of  the  cotton  plugs  extends  to  their  em- 
ployment in  filling  the  whole  canal.  Such  free  use,  however,  of  so 
loose  a  material  may  not  be  indorsed  except  for  teeth  of  the  most 
solid  structure.  Gold  is,  without  doubt,  the  very  best  material 
which  may  be  used,  sealing  as  it  does  the  cavity  with  an  impervi- 
ousness  which  is  the  highest  requirement  of  all  such  cases.  A 
common  fault  with  canal  fillings  of  gold  is  that  the  operator  fails  in 
carrying  the  metal  to  the  apex  of  the  cavity,  thus  permitting  the 
existence  of  a  receptacle  in  which  accidental  deposits  at  once 
become  foreign,  being  removed  from  the  functional  offices  of  vital 
parts  which  are  alone  capable  of  a  demanded  antagonism.  A  canal 
solidly  full  to  the  very  foramen,  any  exudate  which  may  occur  must 
be  associated  necessarily  with  absorbent  vessels  which  adjoin,  no 
road  of  ingress  into  the  tooth  canal  being  open. 

A  source  of  disease  equally  to  be  guarded  against  exists  in  the 
accident  of  forcing  the  root  filling  entirely  through  the  foramen. 
This  may  occur  only  where  foramina  are  enlarged,  either  because 
of  natural  condition  or  from  absorption.  Such  an  accident  the  prac- 
titioner may  guard  against  by  informing  himself  as  to  the  condition 
of  the  opening  through,  exploration  by  the  broach.  If  the  part  is 
normal,  the  sense  of  touch  will  discover  to  him  a  closed  cavity  ;  if 
abnormal,  he  will  feel  the  instrument  impinging  upon  soft  parts 
which  will  be  associated  with  pain  to  the  patient ;  or,  where  a  fora- 
men is  not  specially  enlarged,  the  broach  will  be  felt  to  enter  a  con- 
striction.     A  discovery  thus  made,  the  filling  is  influenced  in  the 


THE   TEETH  AND    THEIR   DISEASES.  389 

depth  to  which  it  is  to  be  carried,  by  a  measurement  secured  by  the 
broach. 

In  the  use  of  so  delicate  an  instrument  as  a  broach,  great  care 
is  to  be  exercised  that  the  instrument  sliall  not  become  jammed  in  the 
canal, — perhaps,  as  has  been  the  case,  in  the  foramen, — and,  break- 
ing, leave  a  cause  of  offense  which  may  result  not  alone  in  the  loss 
of  the  tooth,  but  which,  in  more  than  a  single  instance,  has  caused 
loss  of  life  from  tetanus.  Should  such  accident  occur,  every  eifort 
is  to  be  made  to  remove  the  broken  fragment ;  the  desired  result 
being  generally  attained  by  catching  the  piece  in  a  wisp  of  dry 
cotton  revolved  about  it  by  means  of  a  second  broach.  Where  a 
broach  has  been  caught  and  broken  in  the  foramen,  it  will  be  found 
necessary  to  enlarge  the  opening  by  means  of  the  spear-drill, — a 
practice  the  necessity  for  which  will  be  found  unfortunate,  as  almost 
invariably  does  it  result  in  necrosis  of  the  root  so  treated. 

The  conducting  facility  of  gold  being  well  recognized,  the  use  of 
a  non-conducting  substance  placed  between  the  plug  in  tiie  canal 
and  that  which  is  to  occupy  the  crown  is  appreciated.  Teeth  not 
so  treated  are  subjected  to  a  source  of  continuous  iri'itation  to  which 
very  many  succumb,  a  chronic  inflammation,  resulting  in  necrosis, 
being  the  result  of  the  varying  thermal  impressions.  Founded  on 
such  experience,  the  practice  therefore  is  pursued  of  filling  the  pulp 
chamber  proper — that  is,  that  cavity  out  of  which  run  the  canals — 
with  such  preparations  as  the  oxychloride  of  zinc  or  gutta-percha, 
the  former  to  have  the  preference. 

The  canal  and  pulp  chamber  of  a  tooth  filled,  experience  demon- 
strates the  desirability  of  rest  to  the  organ  of  a  few  days  before  per- 
forming the  crown  operation,  the  cavity  to  be  temporarily  filled  with 
a  sandarac  cotton  plug. 

Filling  OVER  Exposed  Pulp. — So  common  has  the  practice  now 
become  of  attempting  the  performance  of  the  filling  of  complicated 
cavities  and,  at  the  same  time,  the  saving  of  the  pulp,  that  in  the 
operation  dental  writers,  in  their  multitudinous  suggestions,  are  too 
frequently  found  forgetful  of  the  general  principles  which  underlie 
necessarily  all  such  character  of  manipulations. 

Upon  a  former  page,  mention  was  made  of  three  sequelae  associated 
with  exposure  of  the  pulp.  These  three  conditions  are  as  naturally 
conjoined  with  the  relation  as  is  the  immediate  union  of  a  wound 
with  hyperplastic  blood,  or  non-union  with  the  extremes  of  syphilis 
and  scrofulosis.     Whether,  therefore,  or  not,  it  is  worth  while  to 


390  ORAL  DISEASES  AND   SURGERY. 

attempt  the  saving  of  an  exposed  pulp,  will  depend  exclusively  and 
strictly  upon  the  common  condition  of  the  individual. 

That  the  vitality  of  an  exposed  pulp  may  be  presei'ved,  and  a  tooth 
so  affected  be  treated  and  filled,  is  a  fact  attested  by  record  too  reli- 
able to  be  denied ;  but  that  such  success  is  associated  more  closely 
with  physiological  relation  than  with  mechanical  skill  requires  only 
experience  to  become  to  every  observer  a  self-evident  fact. 

Assuming  the  existence  of  such  condition  as  shall  justify  the 
attempt  to  save  an  implicated  pulp,  attention  may  be  invited  to  the 
methods  of  practice  found  by  experience  to  be  the  most  applicable. 

Taking,  as  a  first  illustration,  a  case  where  the  pulp  should  be 
scarcely  exposed,  but  be  found  overlaid  by  a  layer  of  devitalized 
dentine,  it  has  become  the  quite  common  practice  to  trust  such  layer 
to  the  offices  of  nature,  allowing  it  to  remain,  rather  than  expose  the 
pulp  chamber,  trusting  that  through  some  means  the  foreign  body 
may  be  taken  care  of,* — a  desired  result  which  does  not  unfrequently 
occur,  as  case  after  case  on  record  satisfactorily  exhibits.  In  placing 
a  filling,  however,  over  such  diseased  dentine,  it  is  desirable  first  to 
put  it  in  a  state  of  neutrality;  that  is,  tests  are  to  be  made  for  acid 
or  alkaline  conditions,  and,  if  either  state  be  found,  it  is  to  be  an- 
tagonized; fungi,  an  almost  constant  inhabitant  of  such  devitalized 
dentine,  are  to  be  destroyed :  in  short,  if  vitality  may  not  be  restored, 
causes  of  change  and  disintegration  are  to  be  removed. 

A  plate  of  living  dentine,  be  it  ever  so  thin  in  the  centre,  but 
having  circumferential  relations  suflScient  for  the  maintenance  of  its 
vitality,  is  to  be  viewed  as  a  condition  which,  properly  assisted, 
will  tend  to  grow  better  rather  than  the  reverse. 

A  plate  of  dentine,  on  the  contrary,  with  very  limited  parietal 
relations,  will  be  found  much  more  disposed  to  degenerate  than  to 
maintain  or  increase  its  resistive  force. 

Cavities  of  decay  opening  into  the  pulp  chamber  are  treated  in  a 
variety  of  ways.  Of  the  means  adopted,  the  various  modes  em- 
ployed will  with  advantage  be  studied,  as  it  is  a  common  experience 
that  the  unsatisfactory  and  unreliable  character  of  any  or  all  of  them 
tempts  the  practitioner  to  try  each  in  its  turn. 

A  means  at  the  present  time  enjoying  the  largest  favor  is  the 
employment,  as  a  capping,  of  the  preparation  described  as  the  0x3'- 

*A  layer  of  devitalized  dentine  may  be  liquefied  and  absorbed,  or  it  may 
become  encysted;  that  is  to  say,  between  it  and  the  pulp  may  be  deposited  a 
layer  of  secondary  dentine. 


THE    TEETH  AND    THEIR   DISEASES.  391 

chloride  of  zinc.  It  has,  however,  become  a  too  commoa  habit  to 
treat  of  this  substance  as  a  specific  in  the  direction,  and  with  such 
false  impression  it  is  every  day  used  by  many  with  a  recklessness 
which  has  no  excuse.  That  oxychloride  of  zinc  is  a  most  admirable 
agent  in  such  direction,  employed  with  a  judicious  care,  is  certainly 
not  to  be  denied.  No  substance  introduced  into  a  tooth  seems  to 
exert  greater  influence  in  the  excitation  of  that  action  which  pro- 
duces secondary  dentine  than  does  it;  but  injudiciously  employed, 
no  compound  more  quickly  provokes  antagonistic  inflammatory 
action. 

In  using  oxychloride,  it  certainly  is  not  to  be  understood  that  it 
may  be  plastered  over  an  exposed  pulp  ad  libitum ;  on  the  contrary, 
if  it  is  to  be  used  with  any  prospect  of  satisfactory  result,  every 
consideration  is  to  be  had  to  the  delicate  and  susceptible  nature  of 
the  organ  to  be  treated.  Oxychloride  of  zinc  placed  directly  upon 
an  exposed  nerve  could  only  have  good  results  by  an  accident  which 
should  just  level  the  break  in  the  continuity  of  the  floor  of  the 
cavity,  and  which  should  have  alone  that  most  happy  vascular 
response  which  tends  to  the  formation  of  secondary  dentine.  These 
results,  however,  are  precisely  what  are  claimed  as  the  rule  by 
the  supporters  of  the  practice ;  the  proof  or  disproof  of  the  claim 
the  reader  will,  without  doubt,  incline  at  some  time  or  other  to 
make  for  himself. 

Oxychloride  is  recommended  in  this  volume  as  a  capping;  indeed, 
the  experience  of  the  author  would  lead  him  to  esteem  it  as  the  most 
valuable  of  the  agents  employed, — and  thus  far  does  he  fully  agree 
with  its  enthusiastic  admirers  ;  but  whether  it  is  to  be  used  with 
an  excess  of  the  chloride,  or  with  this  powerful  excitant  neutralized 
as  much  as  possible  by  the  inert  oxide,  must  depend  entirely  ou  the 
character  of  the  tooth  treated.  Again,  the  preparation  is  not  to  be 
brought,  in  its  plastic  state,  into  direct  contact  with  the  pulp,  but 
always  is  it  the  safer  practice  to  have  an  interposed  plate.  As  the 
material  of  such  a  plate,  oiled  paper  may  be  used. 

Again,  in  the  use  of  this  agent  it  is  the  best  plan  to  feel  one's 
way;  success  will  not  unfrequently  be  secured  by  letting  the  appli- 
cation as  first  made  be  so  thin  a  film  as  may  alone  prove  self-sup- 
porting. Upon  such  film,  if  no  response  is  made,  a  second  may  be 
placed,  and  upon  this  second  a  third ;  the  cavity  being  finally  filled 
complete,  and  to  be  thus  allowed  to  remain  until,  from  continued 
or  accruing  comfort,  there  is  reason  to  iafer  that  the  pulp  has 
entirely  accommodated  itself  to  the  new  condition  of  things,  or, 


392  ORAL  DISEASES  AND   SURGERY. 

otherwise,  has  walled  itself  in  by  a  secondary  deposit, — a  period  of 
from  one  week  to  a  year. 

Perhaps  always  is  it  the  result  that  pain,  more  or  less  severe,  is 
experienced  by  the  patient  upon  the  introduction  of  this  preparation. 
Particularly  will  this  be  found  the  case  where  the  mixture  has  been 
prepared  thin,  or  where  a  local  anaesthetic  has  not  preceded  the 
application.  When  such  pain  continues  longer  than  a  few  minutes, 
it  will  be  found  the  safer  practice  to  remove  for  the  time  being  the 
filling,  or  otherwise  it  will  be  necessary  to  call  off  the  persistent 
irritability  through  the  means  of  counter-irritants  applied  to  distant 
parts,  and  also  to  diminish  the  circulatory  force  by  the  exhibition 
internally  of  veratrum  viride.  By  such  means  it  is  not  unfrequently 
the  case  that  quiet  may  be  restored  and  the  desired  protective  con- 
ditions secured. 

In  a  pulp  chamber  fairh'  exposed  a  process  of  capping  commends 
itself.  Of  the  means  and  manner  of  this  manipulation  there  will  be 
found  several.  A  mode  of  making  and  applying  a  cap  indorsed  by 
many  experienced  operators  is  thus  described  by  J.  A.  Kennicott, 
D.d's.  : 

"  A  cap  is  to  consist  of  two  materials  of  opposite  nature  :  the  one 
rigid  and  firm  enough  to  support  the  greatest  possible  pressure  that 
it  may  receive  in  the  process  of  filling  the  cavity  without  yielding, 
and  the  other  soft  and  yielding  enough  to  take  a  perfect  impression 
of  the  pulp  without  injurious  pressure.  Neither  material  must  be 
corrosive  in  the  slightest  degree;  nor  must  there  be  any  incompati- 
bility between  these  and  the  nerve.  The  plastic  material,  or  that 
which  comes  next  the  nerve,  must  also  be  essentially  non-conducting 
and  indestructible.  The  two  materials  thus  needed  are  found  in 
gold  and  gutta-percha.  The  operator  should  have  a  quantity  of 
caps  prepared  from  thin  gold  plate,  of  various  forms  and  sizes,  so 
that  he  may  select  one  to  fill  any  cavity.  They  must  be  swedged 
up  with  a  punch,  in  a  concave  form,  and  the  edges  made  thin  and 
smooth  with  the  file,  or  a  die  might  be  constructed  to  cut  and  shape 
them  of  the  required  form  and  size,  all  at  the  same  operation.  Some 
will  require  to  be  round,  some  oval,  and  some  pyriform.  The  gutta- 
percha, which  can  be  procured  in  the  shops  in  the  liquid  form,  should 
be  evaporated  to  dryness,  then  cut  into  pieces  ranging  in  size  from 
a  grain  of  mustard  to  a  No.  10  shot.  After  .selecting  a  cap,  which 
must  be  large  enough  to  cover  the  expo.sed  pulp  and  rest  upon  a 
solid  margin  of  dentine  beyond  it,  the  operator  will  place  in  it  a 
piece  of  gutta-percha  sufficiently  large  when  melted  to  fill  the  cou- 


THE   TEETH  AND    THEIR  DISEASES.  393 

cavity  and  to  extend  somewhat  above  it.  Then  hold  the  cap  over 
the  flame  of  a  spirit-lamp  until  the  gutta-percha  is  melted,  and  with 
a  smooth-faced  plugger,  the  point  of  which  has  been  warmed  and 
slightly  smeared  with  the  melted  gutta-percha,  touch  the  convex 
side  of  the  cap,  when  it  will  adhere,  and  afford  a  very  convenient 
means  of  conveying  it  to  the  required  position  in  the  cavity.  Now 
warm  a  larger  instrument  to  about  one  hundred  and  twenty  degrees, 
and  place  it  against  the  cap  and  press  it  gently  down  until  it  rests 
firmly  upon  the  surrounding  hard  parts,  and  until  the  surplus  gutta- 
percha escapes  from  beneath  it.  This  surplus  material  may  be 
removed,  or  it  may  be  left  as  a  protection  to  the  sensitive  dentine. 
It  is  essential  that  the  gutta-percha  be  warmed  until  it  is  sufficiently 
limpid  to  adapt  itself,  without  sensible  compression,  to  the  delicate 
soft  parts. 

"  In  case  a  portion  of  the  nerve  has  been  destroyed,  the  walls  of 
the  pulp  cavity  should  be  countersunk  with  a  proper  drill  nearly  to 
the  exposed  surface  of  the  remaining  portion,  and  the  balance  of  the 
operation  proceeded  with  as  already  described." 

The  mode  just  described  is  modified  by  some,  who,  deeming  the 
gutta-percha  to  be  rather  a  source  of  offense  than  of  protection,  leave 
it  out  of  the  cap.  Still  another  modification  consists  in  filling  the 
cap  with  the  oxychloride,  and,  when  this  has  become  hard,  cutting- 
it  out  in  concave  form  and  thoroughly  polishing  the  surface. 

A  second  mode  of  capping  an  exposed  pulp  consists  in  taking  a 
piece  of  clarified  quill,  and,  cutting  and  scraping  it  into  a  required 
shape  and  thinness,  laying  it  over  the  break,  the  circumference  being 
supported  by  the  bounding  hard  parts.  While  held  in  place  with 
a  delicate  instrument,  it  is  to  be  fixed  by  a  plug  of  oxychloride  of 
zinc  being  placed  upon  it,  this  zinc  being  afterward  removed  in 
part  for  the  accommodation  of  the  permanent  filling. 

Still  another  manner  of  accomplishing  the  proposed  protection  is 
found  in  the  use  of  a  layer  of  oiled  silk  or  vellum.  These  are  most 
suitable  as  non-conducting  qualities  are  considered,  but  are  objec- 
tionable as  permanency  is  concerned. 

Other  preparations  used  for  capping  are  lead,  tin,  asbestos,  and 
the  Hill  stopping.  A  plan  which  many  think  to  be  commended 
by  results  consists  in  inclosing  asbestos  between  layers  of  gold-foil, 
and,  with  the  metal  thus  stiffened,  arching  it  over  the  exposed  pulp. 

Dr.  Alport,  of  Chicago,  a  skillful  dentist,  has  proposed — and  pro- 
fesses to  have  practiced  with  a  success  ^entirely  satisfactory — the 
following  delicate  operation:  Exposing  fully  the  pulp,  he  takes  out 


394  ORAL  DISEASES  AND   SURGERY. 

of  the  body  of  the  organ  a  V-shaped  piece,  bringing  afterward  the 
lips  together,  and  so  retaining  the  apposition  as  to  secure  an  imme- 
diate union.  The  necessity  for  such  an  operation,  however,  might 
only  occasionally  apply. 

In  the  case  of  a  pulp  exposed,  with  the  orifice  of  the  exposure 
being  jagged,  sharp,  and  irregular,  necessit}'' exists  for  such  enlarge- 
ment and  dressing  of  the  same  as  shall  insure  the  organ — enlarging 
from  time  to  time,  because  of  functional  office — from  irritation  and 
strangulation.  To  accomplish  such  dressing,  it  will  be  desirable  to 
constringe  the  pulp  by  such  means  as  may  be  found  best  to  answer 
the  end.  Tannin  in  a  menstruum  of  glycerine  is  a  favorite  prepa- 
ration with  many.  Alum-water  is  an  excellent  application ;  the 
tincture  of  nutgalls  is  another. 

A  very  effective  plan  consists  in  conjoining  with  the  local  means 
hot  foot-baths,  calling  the  excess  of  blood  away  from  the  head ;  also 
the  administration  of  medicines  which  tend  to  diminish  the  pro- 
pulsive force  of  the  heart, — the  tincture  of  veratrum  viride  being 
perhaps  the  best  of  such  agents. 

An  orifice,  as  described,  being  enlarged  and  dressed,  capping  is  to 
be  resorted  to. 


I 


CHAPTER   XV  I, 


THE   EXTRACTION    OP    TEETH, 


Indications  for  Extraction. — 1,  Teeth,  or  roots  of  teeth,  which 
have  lost  their  vitality,  and  vi^hich  have  become  so  much  loosened 
as  to  be  agents  of  ofifense  and  injury  to  surrounding  parts, 

2.  Posterior  teeth,  which,  from  absence  of  antagonizing  teeth,  are 
rising  from  their  alveoli,  and,  through  the  displacement,  have  become 
a  source  of  pain  or  inconvenience. 

3.  Teeth  having  fungoid  excrescences  growing  from  the  pulp 
cavity. 

4.  Teeth  having  associated  with  them  incurable  abscesses,  threat- 
ening complications. 

5.  Teeth,  particularly  the  premolars,  so  crowded  and  wedged 
into  the  arch  as  to  contribute  to  undue  lateral  pressure.  (See  page 
142.) 

6.  Posterior  teeth  inferred  to  contain  nodules  of  osteo-dentine, 
being  themselves  painful,  or  associated  with  sympathetic  neuralgia. 
(See  page  374.) 

7.  Teeth  recognized  as  associated  with  antral  disease. 

8.  Teeth  that  are  worn  into  the  pulp  cavities  (see  page  378),  or 
so  close  upon  the  gums  as  to  render  mastication  painful, 

9.  Teeth  so  badly  affected  by  caries — being  painful  or  offensive 
— as  to  afford  no  prospect  of  usefulness. 

10.  All  roots  of  teeth  about  which  the  gums  are  congested  and 
debased. 

11.  All  roots  which  are  sources  of  pain  or  discomfort. 

12.  All  roots  in  which  decay  is  progressing. 

The  extraction  of  a  tooth  is  an  easy  or  difficult  matter,  according 
as  the  principles  involved  in  the  operation  are  clearly  or  obscurely 
comprehended.  In  the  adult  mouth  there  are  thirty-two  teeth,  and 
these,  as  the  study  of  their  extraction  is  concerned,  are  compre- 
hended under  six  classes, 

(395) 


396 


ORAL  DISEASES  AND  SURGERY. 


The  first  of  these  classes  embraces  the  eight  central  and  lateral 
incisors,  teeth  with  cone-like  roots,  and  accommodated  in  alveoli 
representing-  hollow  cones. 

Fig.  131. — Permanent   Teeth  of  Upper  Jaw. 


Fig.  132. — Permanent  Teeth  of  Lower  Jaw. 


Eigs.  IJI,  lv2:  DiAOR.vM  OF  Teeth. — 1,  2,  iucisois  ;  ^,  4,  .J,  bicu.spid.iu,  ui- .-ui.ill  iiicilars;  6,  7,  S, 
large  molars,  or  grinders. 

The  second  class  embraces  the  cuspidati,  represented  by  the  partly 
flattened  cone. 

The  third  class  embraces  the  bicuspidati,  represented  by  the  flat- 
tened cone. 

The  fourth  class  embraces  the  superior  first  and  second  molars, 
teeth  having  three  roots, — two  external  cone  roots,  situated  antero- 
posteriorly,  with  the  interspaces  looking  toward  the  cheek,  and  the 
third,  generally  a  flattened  root,  looking  toward  the  palatine  arch. 

The  fifth  class  embraces  the  inferior  first  and  second  molars,  teeth 
having  two  roots,  one  looking  anteriorly,  the  other  posteriorly  ;  the 
interspace  looking  outward  and  inward. 

The  sixth  class  embraces  the  four  wisdom-teeth.  These  are 
single-rooted  as  a  rule,  with  a  curve  looking  backward. 


To  extract  a  tooth  of  the  first  class,  the  application  of  the  force  is 


THE   EXTRACTION  OF  TEETH. 


397 


I 


required  in  a  twofold  direction,  rotatory,  and  downward  or  upward, 
as  the  case  may  be. 

To  extract  a  tooth  of  the  second  class,  the  force  is  required  in  a 
threefold  direction,  downward  or  upward,  lateral,  and  rotatory. 

To  extract  a  tooth  of  the  third  class,  upward  or  downward,  and 
lateral,  or  inward  and  outward,  as  one  loosens  a  nail. 

To  extract  a  tooth  of  the  fourth  class,  the  same  application  of  the 
force;  one-half  of  such  a  tooth  is,  however,  to  be  extracted  at  a 
time, — that  is,  we  first  break  the  attachment  of  either  the  inner  or 
outer  roots,  and,  feeling  these  yield,  the  force  is  instantly  brought  to 
bear  upon  the  other.  In  extracting  teeth  of  this  class  in  this  man- 
ner, much  care  is  necessary  in  guarding  against  a  too  great  extent 
of  lateral  motion  ;  otherwise  the  roots,  instead  of  yielding,  will  be 
found  to  break,  thus  complicating  matters  very  seriously. 

Teeth  of  the  fifth  class  require  the  lateral  and  direct  application 
of  the  force;  they  are  to  be  gently  rocked  inward  and  outward  until 
felt  to  yield,  when  they  are  at  once  to  be  lifted  from  their  sockets. 

Teeth  of  the  sixth  class  are  to  be  carried  backward  and  upward, 
or  downward,  in  the  line  of  the  axis  of  their  single  curved  root. 
Such  applications  will  make  easy  an  extraction  which  might  other- 
wise be  attended  with  much  risk. 


instriTments. 

Instruments  are  now  made  in  consideration  of  the  anatomical 
peculiarities  of  the  teeth  for  which  they  are  intended.  The  better 
class  are  nickel-plated,  to  insure  against  rust,  and  are  of  such 
quality,  as  the  character  of  the  steel  is  concerned,  that  they  will 
retain  the  outline  and  sharpness  of  blades  through  much  service. 
No  instruments  but  those  of  such  quality  are  worthy  of  purchase. 
We  now  describe,  with  manner  of  use,  such  as  have  most  com- 
mended themselves. 


Fig.  183. — Upper  Incisor. 


398  ORAL   DISEASES  AND   SUBGERY 

Fig.  134  — Upper  Lateral  Incisor. 


Fig.  135. — Lower  Incisor,  Hawk-Bill 


Fig.  136. — Lower  Incisor  and  Bicuspid,  for  Either  Side. 


Fig.  137. — Hawk-Bill,  Lower  Incisor,  and  Crowded  Teeth. 


Figs.  133  to  13Y  represent  forceps  designed  for  the  extraction  of 
the  incisor  teeth.  Referring  to  Figs.  L31,  132,  Nos.  1  and  2,  or, 
what  is  practically  much  better,  examining  the  organs  themselves, 
the  reader  will  perceive  that  these  teeth  fully  represent,  as  we 
have  stated,  double  cones,  the  bases  abutting  just  beneath  the  free 
margin  of  the  gum.     To  secure  a  fixed,  unyielding  hold  of  a  body 


THE  EXTRACTION  OF   TEETH.  399 

so  shaped,  it  would  strike  the  intelligence  of  any  operator  that  the 
forceps  should  be  so  constructed  as  to  accommodate  the  width  of 
the  base,  yet  at  the  same  time  grasp  firmly  the  retreating  cones. 
Turning  here  the  examination  to  the  forceps,  these  indications  are 
found  to  be  fully  met.  The  fenestrum,  made  when  the  blades  are 
closed,  forms  an  ellipse,  the  widest  part  of  which  corresponds  with 
the  base  of  the  teeth.  The  apices  correspond  so  in  form  with  the 
cones,  and  the  concavities  of  the  blades  so  adapt  themselves,  that, 
applying  the  instruments,  they  are  found  fitted  to  the  teeth  with  the 
nicest  accuracy;  indeed,  as  suited  to  the  purpose,  nothing  seems  left 
to  desire. 

Fig.  133,  upper  incisor,  is  a  straight  forceps,  designed  for  the 
superior  incisors,  and  which,  where  the  under  jaw  is  well  withdrawn, 
answers  very  well  for  the  cuspidati.  The  roots  of  the  incisor  teeth 
are  understood  to  be  rounded  cones,  having  corresponding  alveoli. 
These  teeth  are,  perhaps,  the  most  easily  extracted  of  any  in  the 
jaws.  Thrusting  the  blades  well  beyond  the  neck  of  the  tooth,  the 
curve  in  the  handle  receiving  the  little  finger,  and  looking  towards 
the  body  of  the  patient,  having  the  head  resting  either  in  the 
support  of  the  ordinary  dental  chair,  or  against  the  chest  of  the 
operator,  whose  left  arm  is  to  be  thrown  around  it  to  secure  fixed- 
ness (and  which  position  applies  to  all  the  upper  teeth),  a  force  is 
to  be  applied,  which,  while  drawing  downward,  rotates  or  twists 
the  organ  from  its  socket.  If,  however,  the  resistance  prove  too 
great  for  a  single  twist, — which,  in  heavy  jaws,  is  almost  certain  to 
be  the  case, — then  the  motion  is  to  be  reversed,  the  direction  of  the 
twist  being  alternated  until  the  tooth  is  felt  to  yield,  when,  without 
further  effort,  it  may  be  drawn  from  its  socket. 

Fig.  134  represents  a  forceps  designed  for  the  upper  lateral  incisors. 
The  ellipse  is  seen  to  differ  a  trifie  from  that  of  the  preceding  instru- 
ment; this  adapts  it  to  a  corresponding  difference  in  the  tooth.  It 
difiTers  principally,  however,  in  having  the  blades  made  narrower. 
The  application  of  this  forceps  is  precisely  the  same  as  that  em- 
ployed in  the  case  of  the  central. 

Figs.  135  to  142  represent  forceps,  all  of  which  find  an  adaptation 
to  the  inferior  incisors,  central  and  lateral,  the  cuspidati,  and  the 
bicuspidati. 

When  directed  to  tliese  teeth,  the  operator  may  stand  either  in 
front  of  his  patient,  or  (a  position  more  commonly  preferred)  he  may 
seat  the  patient  upon  a  low  chair,  leaning  over  his  head,  or  over  the 
right  or  left  shoulder,  as  found  most  convenient. 


400  ORAL  DISEASES  AND   SURGEBY. 

Fig.  138. — Upper  and  Lower  Root,  Half  Curved. 


Fig.  139. — Lower  Eoot,  Full  Curved. 


Fig.  140 — Upper  and  Lower  Bicuspid,  Half  Curved 


Fig.  141. — Upi'er  Back  Koot  (universal). 


Fig.  142. — Half  Curved,  Narrow  Beak,  for  Crowded  Teeth. 


Fig.  141  is  also  a  forceps  adapted  to  the  extraction  of  the  inferior 
incisor  teeth.  Grasping-  the  tooth  by  forcing  the  blades  as  far  down 
as  possible,  keeping  them  confined  closely  to  the  organ,  that  thus 
they  may  be  directed  between  the  tooth  and  its  alveolus,  the  rounded 
root  of  the  central  may  generally  with  much  ease  be  broken  from  its 


THE  EXTRACTION  OF  TEETH.  401 

attachments  by  an  upward  and  rotatory  movement.  If,  however, 
with  a  very  reasonable  application  of  force  so  applied  it  is  not  felt  to 
yield,  the  strain  is  not  to  be  increased  to  a  risk  of  breaking  the  tooth, 
but  a  lateral  motion  inward  and  outward  may  be  tried,  or  this  con- 
joined with  the  rotatory.  This  root  being  sometimes  considerably 
flattened,  makes  such  lateral  motion  necessary.  If  very  narrow  or 
crowded,  the  forceps  represented  by  Fig.  142  may  be  used.  In  re- 
moving the  inferior  lateral  incisors  the  rotatory  movement  is  to  be 
employed,  which  may  have  combined  with  it  slight  lateral  motion, 
although  this  latter  will  not  be  found  of  much  import,  unless  in 
exceptional  cases,  where  the  roots  happen  to  be  markedly  flattened. 
The  bicuspidati  all  have  fiat  roots,  and,  so  far  as  the  conditions  of 
extraction  are  concerned,  are  to  be  viewed  as  possessing  but  a  single 
root.  These  teeth  are  to  be  removed  just  as  a  nail  is  worked  from 
a  board  into  which  it  has  been  loosely  driven, — a  motion  inward  and 
outward  quickly  breaking  the  attachment.  The  position  of  operator 
and  patient  is  the  same  as  just  suggested. 

Fig.  143. — Upper  Bicuspid  and  Canine. 


Fig.  143  designates  a  forceps  adapted  equally  well  to  the  ten  ante- 
rior upper  teeth.  It  may  justly  be  termed  a  faultless  instrument. 
For  myself,  I  certainly  give  it  the  preference  over  all  that  I  have  ever 
seen  for  the  purposes  intended  :  indeed,  I  incline  to  think  that  with 
it  any  tooth  in  the  mouth  could  be  extracted  in  an  emergency. 
Applying  this  instrument  to  any  one  of  these  ten  anterior  teeth,  it 
is  seen  to  be  possessed  of  most  satisfactory  adaptation,  the  curve 
in  the  blades  and  handles  clearing  the  lower  lip  to  an  extent  affor«i- 
ing  the  greatest  freedom  in  motion,  while  the  support  curve  in  the 
handle  prevents  the  possibility  of  change  in  the  grasp. 

The  root  of  a  cuspidate  is  perhaps  the  most  firmly  fixed  in  its 
alveolus  of  all  the  teeth  of  the  jaw.  Occupying  as  it  does  the  po- 
sition of  a  keystone  to  an  arch,  to  extract  this  tooth  both  strength 
and  skill  are  required.     In  shape,  the  root  is  found  to  be  a  partly 

26 


402 


ORAL  DISEASES  AND  SURGERY. 


rounded,  partly  flattened  cone;  its  alveolus,  of  course,  corresponds. 
In  length  it  is  greater  than  the  adjoining  teeth, — in  many  instances 
to  the  extent  of  a  third, — and,  while  generally  straight,  is  yet  fre- 
quently to  be  met  with  having  an  apex  curved  at  varying  angles, 
such  curvature,  however,  being  confined  to  the  extreme  end.  To 
extract  this  tooth,  the  organ  is  grasped  by  working  the  blades  of  the 
forceps  as  much  below  the  edge  of  the  process  as  possible,  and,  while 
a  firm  compressing  force  is  maintained,  the  tooth  is  gradually  ro- 
tated, and  also  worked  inward  and  outward.  If,  after  a  moment, 
it  should  be  felt  to  yield,  and  yet,  while  moving  with  more  or  less 
freedom  in  its  socket,  seem  to  be  held  by  some  attachment,  the 
operator  is  to  cease  his  efforts,  that  he  may  satisfy  himself  that  the 
loosening  resides  not  in  a  fractured  alveolar  process  or  in  a  retaining 
flap  of  gum.  If  neither  of  these  complications  exists,  he  may  again 
seize  the  tooth,  and,  understanding  that  the  retention  depends  on 
curvature  of  the  fang,  attempt  to  get  it  away  by  findiug,  through 
various  movements,  the  direction  which  affords  the  least  resistance  : 
this  discovered,  it  is  to  be  worked  out  even  at  the  risk  of  fracturing 
the  curved  apex.  No  tooth  requires  to  be  more  thoroughly  and  deeply 
lanced  than  the  canine. 


Fig.  144. — Upper  Bipuspid  and  Incisor. 


Fig.  145 — Lowkr  Bicu.^pid  axd  Canine. 


I 


Figs.  140,  143-147,  are  instruments  designed  by  different  oper- 
ators for  the  extraction  of  the  bicuspidati  and  cuspidati.     These 


THE   EXTRACTION  OF  TEETH. 


403 


forceps  will  be  remarked  to  vary  considerably  in  shape.  Fig.  140  is 
one  found  to  have  most  frequent  application,  being  useful  alike  in 
the  superior  and  the  inferior  jaw.     Unless  it  is  designed  to  furnish  a 

Fig.  146. — Lower  Bicuspid,  Safety. 


Fig  147. — Upper  Bicuspid,  Safety. 


case  with  all  the  numbers,  this  may  with  most  satisfaction  be 
selected.  Fig.  145  is  an  excellent  instrument,  particularly  appli- 
cable to  the  lower  jaw  when  the  teeth  are  set  well  back  and  the 
commissure  is  small  and  unyielding. 

Fig.  148. — Upper  Molar,  Eight  and  Left  (Harris's). 


Figs.  148  to  151  represent  forceps  designed  for  the  extraction  of 
the  superior  molar  teeth.  On  examining  the  blades  of  any  of  these 
instruments,  the  outer  will  be  seen  to  run  to  a  nib  at  its  centre, 
while  the  inner  is  plain.     These  correspond  with  the  anatomical 


404  ORAL  DISEASES  AND  SURGERY. 

Tig.  149. — Upper  Molar,  Eight  and  Left. 


Fig.  150. — Upper  Molar,  Eight  axd  Left. 


Fig.  151. — Upper  Molar,  for  Either  Side. 


indications  of  the  teeth  upon  which  they  are  to  be  used,  as  is  seen 
by  glancing  at  Figs.  131,  182,  Nos.  6  and  7.  To  apply  these  forceps, 


THE  EXTRACTION  OF  TEETH.  405 

the  triangular  blade  must  correspond  with  the  outer  face  of  the  tooth. 
Having  the  instrument  well  in  position,  which,  it  will  be  recognized, 
places  the  point  of  the  outer  blade  in  the  interspace  made  by  the 
bifurcation  of  the  buccal  roots,  and  the  concave  plain  inner  blade 
against  the  palatine  root,  the  force  is  to  be  so  applied  as  to  break  the 
attachments  at  separate  motions;  this  is  easily  accomplished  by 
the  process  of  rocking  the  tooth  outward  and  inward.  A  lateral 
movement  is  not  to  be  great,  that  fracture  may  be  avoided.  The 
position  of  operator  and  patient  is  as  before  described  for  other 
upper  teeth. 

It  is  not  always  the  case,  however,  that  these  teeth  are  found  as 
represented  in  the  drawing.  Sometimes  as  many  as  five  roots  exist, 
and  these  so  diverging  as  to  render  the  extraction  of  all  of  them, 
without  fracture,  a  very  difficult  matter,  perhaps  indeed  impossible, 
particularly  if  the  jaw  be  heavy  and  the  alveolar  process  dense.  At 
other  times  it  will  be  seen  that  the  roots  have  commingled,  forming 
an  irregular  conical  fang.  This  latter  condition  facilitates,  of  course, 
extraction.  Another  condition  not  unfrequently  met  with  is  a  con- 
vergence of  the  apices  of  the  roots,  these  so  grasping  the  inclosed 
process  that,  in  the  coming  away  of  the  tooth,  either  the  fangs  must 
spring  to  such  extent  as  to  permit  the  passage,  or  this  piece  of  bone 
must  come  with  it. 

Again,  it  is  sometimes  seen  that  a  molar  tooth — although  this  is 
much  more  common  to  the  bicu.spidati — stands  to  the  inside  of  the 
arch,  being  wedged,  as  it  were,  out  of  its  place.  Here  the  rocking 
motion  is  necessarily  modified.  The  tooth  is  first,  with  gentle  yet 
steady  force,  to  be  carried  inward,  then  back  to  the  point  of 
departure.  This  is  to  be  repeated  until  the  attachments  are  broken. 
Cases  also  present,  but  they  are  very  rare,  where  a  tooth  desired  to 
be  removed  is  more  or  less  overlaid  by  its  fellows.  Here  it  will 
most  likely  be  necessary  to  resort  to  the  use  of  the  file,  or  recourse 
may  be  bad  to  wedging  away  the  opponent  teeth  by  means  of  slips 
of  india-rubber  worked  between  the  teeth  while  held  on  the  stretch- 
Such  wedges,  after  being  retained  for  a  few  hours,  will  not  unfre- 
quently be  found  to  secure  room  quite  sufficient  for  the  passage. 
Where  undue  crowding  is  found  to  depend  on  proximal  caries  of 
the  tooth  to  be  extracted,  it  will  be  found  all-sufficient  to  chisel 
away  the  part  intruded  on. 

Instrument  Fig.  151  is  of  such  construction  as  to  permit  its  appli- 
cation to  the  superior  molars  of  either  side.  It  is,  of  course,  not  an 
anatomical  forceps,  but  when  the  teeth  to  be  extracted  are  solid  and 


406 


ORAL  DISEASES  AND  SURGEBY. 


resistive  it  answers  its  end  tolerably  well.     It  is  not,  however,  to 
be  commended. 

Fig  lr)2.  These  are  instruments,  in  pairs,  designed  for  the  extrac- 
tion of  the  superior  molar  teeth.  They  are  known  as  the  Maynard, 
or  cow-horn.  Than  these  forceps,  it  would  seem  that  none  could 
be  devised  meeting  more  happily  the  anatomical  requirements  of 
Class  IV. 

Fig.  152. — Upper  Molar,  Right  and  Left,  Cow-Horn,  with  or  without 
Hook  ox   Handle. 


The  outer  beak,  horn-shaped,  is  designed  to  enter  the  interspace 
between  the  buccal  roots;  the  inner — flat,  square  of  blade,  and 
grooved — adapts  itself  accurately  and  firmly  to  the  palatine  fang. 

To  apply  these  forceps,  the  operator  stands  to  the  right  of  his 
patient,  precisely  as  in  the  case  of  teeth  of  the  first  three  classes,  the 
left  arm  passing  around  the  head,  the  fingers  of  the  left  hand  holding 
the  lip  out  of  place.  In  using  the  Maynard  forceps,  care  must  be 
taken  to  thrust  the  point  of  the  horn  directly  into  the  interspace, 
otherwise  the  operator  would  have  no  hold  on  the  tooth;  this  being 
in  position,  the  flat  blade  is  carried  along  the  palatine  fang  as  high 
as  possible.  A  few  rocks  of  the  tooth  inward  and  outward,  com- 
bined with  a  direct  force  in  the  line  of  its  long  axis,  and  it  will  be 
found  to  give  way. 

Fig.  153  is  an  instrument  of  similar  construction,  differing,  how- 
ever, in  an  arrangement  of  blade-curvature  which  permits  of  its 
application  to  the  teeth  of  either  side. 


THE   EXTRACTION  OF   TEETH.  407 

Fig.  153 — Uppek  Molar,  Cow-Horn,  Either  Side. 


Fig.  154  is  a  forceps  intended  for  the  lower  molars  and  the  dentes 
sapientise  of  either  side.  The  molars  of  the  inferior  jaw  are  two- 
rooted  (see  Figs.  131,  132),  with  the  interspace  looking  outward  and 

Tig.  154  — Lower  Molar,  Either  Side  (Harris's). 


inward.  Examining  the  instrument,  it  will  be  seen  that  the  blades 
terminate  in  sharp,  central  nibs,  the  design  of  such  points  being 
to  fit  as  accurately  as  possible  the  depressions  made  by  the  division. 
When  the  crown  of  a  tooth  is  strong  and  resisting,  or  where  a  loose 
process  permits  of  a  hold  which  carries  the  nibs  well  into  the  inter- 
space, this  instrument  may  be  used  to  most  satisfactory  purpose. 
Where,  however,  the  crown  is  much  decayed,  and  consequently  fraii, 
the  cow-horn  forceps,  next  to  be  described,  will  be  found  better 
adapted. 

The  wisdom-teeth  of  the  lower  jaw  have  the  single  curved  root 
corresponding  with  the  upper,  bending  here  toward  the  rami  of  the 
jaw.  Instrument  Fig.  154  allows  of  the  proper  application  of  the 
force  demanded  for  their  extraction  ;  they  are  to  be  lifted  upward 
and  backward.  Wisdom-teeth  crowded  under  the  rami,  and  thereby 
unable  properly  to  erupt,  not  uufrequehtly  become  the  occasion  of 
grave  lesions.  For  instances  of  such  complication,  together  with 
mode  of  treatment,  see  page  176. 

Fig.  155  is  the  lower  cow-horn  forceps.  This  instrument,  designed 
to  be  used  in  the  extraction  of  the  lower  molars,  is  one  of  the  most 
effective  in  the  collection.  To  employ  it,  care  is  to  be  taken  so  to 
apply  the  points  that  the  closure  of  the  handle  forces  them  into  the 


408 


ORAL  DISEASES  AND   SURGERY. 


interspace.  Referring  to  Fig.  132,  thi.s  interspace  is  seen  to  corre- 
spond with  the  exact  centre  of  the  buccal  and  lingual  faces  of 
the  tooth,  and,  examining  its  relation  with  the  alveolar  process,  it  is 

Fig.  155. — Lower  Cow-Horn  Forceps. 


seen  to  be  on  a  level  with  its  border.  When  the  blades  of  the  in- 
strument are  in  position,  it  will  be  recognized  that  the  points  are  to 
occupy  this  interspace;  thus  the  pressure  is  exerted  from  below,  and 
not  at  all  upon  the  walls  of  the  crown,  affording,  in  this  respect, 
such  advantage  that  extent  of  decay  or  brittleness  amounts  to  very 
little.     The  lifting  power  and  leverage  of  this  forceps  are  of  such 

Fig.  156. — Lower  Molar,  Cow-Horn,  Eight  Side. 


Fig.  157. — Lower  Molar,  Cow-Horn,  Left  Sii>e. 


character  that  it  very  frequently  occurs  that  the  mere  closing  of  the 
handle  will  loosen  the  tooth.  When,  however,  this  does  not  occur, 
the  tooth  is  to  be  rocked  until  the  connection  is  felt  to  break.  Ex- 
amining a  tooth  held  in  the  grasp  of  this  instrument,  the  points  of 


THE   EXTRACTION  OF  TEETH. 


409 


the  blades  will  be  found  met  in  the  interspace.  Always,  before 
applying  the  force,  it  is  well  to  have  the  points  thrust  as  deeply  as 
possible  below  the  free  edge  of  the  gum.  When  such  precaution  is 
not  taken,  and  the  sharp  points  do  not  reach  the  interspace,  they 
are  almost  certain  to  produce  fracture.  This  instrument  is,  of  course, 
not  applicable  where  caries  has  proceeded  to  such  an  extent  as  to 
have  separated  the  roots. 

Figs.  156  and  157.  These  are  the  cow-horn  forceps  in  pairs: 
the  shape  of  the  handles,  and  the  curve  for  the  rest  of  the  little 
finger,  add  much  to  convenience  of  employment.  Together,  they 
make  a  very  efficient  set  for  lower  molars. 

Fig.  158  is  a  forceps  designed  for  the  inferior  molars;  it  is  known 
as  Wolverton's  instrument.  It  is  preferred  by  many  as  combining 
the  advantages  of  the  Maynard  and  Harris. 

Fig.  158. — Lower  Molar,  Either  Side  (Wolvekton'.s). 


Fig.  159. — Lower  Molar  (Hutchinson's). 


Fig.  159  is  a  lower  molar  forceps.  In  a  deep  mouth,  and  where 
the  tooth  to  be  extracted  is  much  concealed  by  one  anterior  to  it, 
the  curve  of  the  blade  will  be  found  to  render  it  of  great  service. 
Admirers  of  the  instrument  commend  it  particularly  for  the  shape 
of  the  fenestrum. 

Fig.  160  designates  the  forceps  for  wisdom-teeth  of  upper  jaw, 
either  side.     As  a  rule,  these  teeth  are  found  to  have  but  a  single 


410 


ORAL  DISEASES  AND   SURGERY. 


root.  This,  in  shape,  is  conoidal,  with  a  curve  which  directs  the 
apex  toward  the  tuberosity  of  the  bone.  To  remove  these  teeth 
with  least  effort  and  risk,  this  curve  of  the  root  is  always  to  be  con- 
sidered, requiring  the  extraction  to  be  in  the  line  of  its  axis.  To 
accomplish  such  a  requirement,  the  crown  of  the  tooth,  after  being 
grasped  in  the  beak  of  the  instrument,  is  to  be  directed  backward. 
This  rolls  it,  as  it  were,  wheel-fashion,  from  its  socket.  The  forceps 
Fig.  145  will  also  be  found  well  adapted  for  the  removal  of  these 
teeth  when  they  may  be  sn)all. 

Fig.  IGO. — Upper  Dknte.s  Sapienti^,  for  Either  Side,  with  or 
WITHOUT  Hook. 


It  happens,  however,  that  in  man}'  instances  the  superior  wisdom- 
teeth  have  three,  or  even  more,  bifurcating  fangs:  when  this  is  the 
case,  it  is  quickly  to  be  recognized  by  the  undue  resistance  offered  to 
the  employed  force,  and  its  direction.  No  rule  may  here  be  given 
outside  of  that  which  applies  to  the  neighboring  molars:  the  oper- 
ator, if  the  irregularity  is  very  peculiar,  feels  his  way  by  testing 
for  the  aspect  of  least  resistance. 

Fig.  161. — Physick's  Dextes  Sapientke,  Either  Side. 


Fig.  161  represents  a  forceps  designed  by  the  late  Prof.  Physick 
for  the  extraction  of  wisdom-teeth.  The  instrument  is  seen  to 
represent  a  double  inclined  plane,  and,  in  consideration  of  the  neces- 
sity for  throwing  these  teeth  backward,  is  designed  to  be  applied 
between  the  tooth  to  be  extracted  and  the  one  directly  anterior 
to  it.  The  closure  of  the  handle  is  expected  to  throw  the  tooth 
from  its  socket. 

It  sometimes  occurs,  however,  that  these  teeth,  as  seen  in  the 
superior  tooth  in  the  drawing  (Fig.  131),  have  more  than  a  single 


THE  EXTRACTION  OF   TEETH. 


411 


root ;  and  these  roots,  instead  of  being  inclined  in  a  common  axis,  are 
frequently  spread  out  in  various  directions.  In  cases  of  this  kind 
it  is  plain  that  the  instrument  would  not  apply.  Another  objection 
to  its  use  lies  in  the  injury  apt  to  be  inflicted  on  the  anterior  or  ful- 
crum tooth;  this  not  unfrequently  having  the  enamel  so  crushed  and 
broken  as  to  expose  the  more  susceptible  dentine,  and  thus  lead  to 
caries.  Still  another  objection  lies  in  the  contusion  inflicted  on  the 
periodonteum,  this  membrane  being  occasionally  so  injured  as  to 
result  in  its  severe  inflammation. 

The  ordinary  key  instrument,  when  lightly  and  delicately  made, 
answers  a  very  admirable  purpose  with  this  class  of  teeth.  The 
roots  being  generally  quite  short,  there  is. little  of  the  common 
danger  of  alveolar  fracture,  and  being  but  lightly  set  in  their  sockets, 
and  easily  yielding,  the  application  of  but  very  trifling  force  is 
required. 

In  using  the  key,  the  fulcrum  should  be  placed  on  the  inner  face 
and  well  back  upon  the  tooth,  the  claw  being  upon  the  opposite  face 
and  well  in  front ;  this  application  allows  of  the  proper  direction  of 
the  force,  and  admits  of  the  easy  and  natural  removal  of  the  organ. 

Still  another  instrument  employed  in  the  extraction  of  these 
teeth  is  the  elevator.  (Fig.  167.) 

To  apply  this  instrument,  the  grooved  face  is  laid  against  the 
antero-lateral  aspect  of  the  tooth,  and,  being  carried  down  to  the  pro- 
cess, the  hand  is  depressed  so  that  the  free  edge  of  the  blade  alone 
impinges;  the  tooth  is  then  pushed  outward  from  its  socket,  and 
backward.  When  wisdom-teeth  are  but  ordinarily  adherent,  this  is 
an  admirable  instrument  for  their  removal ;  care,  however,  is  neces- 
sary that  it  shall  not  slip  from  the  tooth  and  inflict  injury  on  the 
neighboring  soft  parts.  Elevator  No.  6  (see  Fig.  161)  is  the  one 
most  commonly  employed. 


Fig.  162  — Lower  Dentes  Sapiknti^,  Either  Side. 


Another  instrument  yet  is  Fig.  162:  long  of  shank,  and  with 
blades  curved  at  right  angles  with  the  handle,  it  answers  a  most 
admirable  purpose  in  the  case  of  the  inferior  wisdom-teeth. 


412 


ORAL   DISEASES  AND   SURGERY. 


♦  Fulcrum  Forceps. — These  instruments,  of  which  seven  consti- 
tute a  set,  act  on  the  principle  of  the  key  and  elevator.  A  glance 
at  their  construction  will  exhibit  the  mode  of  application.  That 
when  skillfully  used  they  are  capable  of  meeting  many  emergencies, 


Fig.  163. — Upper  Incisors,  Cuspids  and  Bicuspids,  for  Eithkr  Side 

OF  THE  Mouth. 


Fio.  164. —  Lower  Incisors,  Cuspids  and  Bicuspids.    (Two  pairs,  one  for 
tlie  right  and  one  for  the  left  side  of  the  mouth.) 


Fig.  165. — Lower  Molar.   (Two  pairs,  one  for  the  right  and  one  for  the  left 
side  of  the  mouth.) 


may  not  be  doubted.  The  forceps  of  this  class  here  figured  are  the 
invention  of  Dr.  E.  M.  Jones,  of  Richmond,  Va.  Another  instru- 
ment of  the  same  general  character,  which,  in  respect  to  the  fulcrum, 
highly  commends  itself,  is  the  invention  of  Dr.  H.  H.  Perrine,  of 
Marvland. 


THE   EXTEACTION   OF   TEETH. 


413 


All  instruments  of  this  class  are,  however,  but  modifications  of 
the  key  of  Garengeot  and  of  the  elevator,  and,  in  the  deserved  com- 


FiG    166. — ITppkr  Molar.   (Two  pairs,  one  for  the  right  and  one  for  the  left 
side  of  the  mouth.' 


mendation  they  receive,  serve  to  exhibit  the  virtue  of  the  instruments 
they  replace.     The  key,  so  long  and  so  completely  abandoned,  should 


Fig.  167. — Elevators  used  in  Extr.acting  Roots. 


414  ORAL  DISEASES  AND  SURGERY. 

not  be  without  its  place  in  an  instrument-case.  With  a  variety  of 
claws  to  fulfill  the  diversified  indications,  and  with  skill  and  care  in 
the  adjustment  of  the  fulcrum,  it  is  a  most  valuable  addition.  An 
advantage  possessed,  hov/ever,  by  the  fulcrum  forceps,  is  easier 
adaptation  of  the  claw,  together  with  a  more  direct  oversight  during 
the  act  of  extraction.  In  applying  either  this  forceps  or  the  key,  it 
is  necessary  to  force  the  blade  as  deeply  as  possible  along  the  root 
of  the  tooth,  and  so  to  arrange  the  pad  that  the  pressure  upon  the 
soft  parts  shall  be  as  little  injurious  as  possible.  Bruising  and 
crushing  the  gums  are  the  objections. 

Concerning  the  fulcrum  forceps,  much  commendation  has  been 
received, — gentlemen  of  experience  considering  them  an  essential 
to  a  satisfactory  success  in  this  direction  of  practice. 

Extraction  of  Fractured  Teeth  and  Roots  of  Teeth. — It  not 
unfrequently  happens  that,  in  attempts  to  extract  teeth,  fractures  re- 
sult ;  and  such  fractures  must,  of  course,  present  the  greatest  variety 
of  aspect,  and  require  various  resources  for  the  removal  of  the  parts 
left. 

Teeth  of  the  first,  second,  and  third  classes  present  the  same  com- 
mon features  of  fracture,  and  may  claim  a  first  attention.  Fig.  168 
represents  the  alveolar  line,  and  the  various  relations  held  to  this 
line,  or  free  border,  by  fractured  teeth  or  roots. 

Tig.  168. — Eelation  of  Fractured  Eoots  to  Alteolar  Line. 

1  2  3  4  5  6        7 


A  fractured  tooth,  as  represented  by  Subfig.  I  (the  first  root  to 
the  left),  is  placed  in  no  worse  condition  for  easy  extraction  than 
before  the  occurrence  of  the  accident.  The  same  forceps  and  the 
same  manner  of  its  application  still  apply  to  it. 

Subfig.  2  represents  a  slight  modification  of  the  same  condition. 
The  one  forceps  and  the  one  application  still,  however,  apply.  It 
is  advisable,  if  the  tooth  is  at  all  brittle,  to  work  the  blades  of  the 
instrument  well  beneath  the  alveolus.  This  affords  greater  support 
and  yields  increased  security. 


THE   EXTRACTION   OF   TEETH. 


415 


Subfig.  3  may  represent  a  bicuspid  tooth  with  the  crown  half 
broken  away.  In  such  a  case,  if  the  remaining  portion  is  not  at  all 
brittle,  and  if  the  process  is  soft  and  spongy,  the  forceps,  as  de- 
scribed, having  well-sharpened  blades,  may  again  be  tried,  working 
them  well  beneath  the  process,  and  securing  all  the  hold  possible  on 
the  root.  If  fracture  again  occurs,  which,  indeed,  is  very  likely, 
simulating  Figures  4  and  5,  the  cutting  forceps  is  to  be  employed. 

To  use  a  cutting  forceps,  make,  with  a  scalpel  or  other  blade,  an 
incision  on  either  side  of  the  root  through  the  soft  parts  directly 
down  to  the  process;  these  cuts  must  correspond  with  the  exact 
centre  line  of  the  root.  The  forceps  is  now  to  be  applied  scissors- 
fashion,  cutting  directly  through  the  bone.  Being  thus  brought  in 
contact  with  the  root,  and  grasping  it  perhaps  full  half  its  length, 
the  removal  is,  of  course,  a  perfectly  simple  matter. 

Some  operators  prefer  to  precede  the  cutting  forceps  with  the 
elevator,  and  this  instrument,  in  many  cases,  certainly  effects  the  end 
very  well. 

In  the  application  of  the  cutting  forceps,  it  not  unfrequently  hap- 
pens that,  from  want  of  care,  the  blades,  instead  of  coming  directly  . 
upon  the  root,  slip  to  the  back  or  front  of  it.  In  these  cases  the 
fang  may  generally  be  easily  enough  picked  out  with  the  ordinary 
root  forceps.  A  form  of  cutting  forceps  used  by  many,  consisting  of 
a  double  curved  blade,  avoids  this  accident,  but  it  is  to  be  objected 
to  on  account  of  the  wound  it  makes. 

Roots,  represented  in  Fig.  168,  Nos.  4,  5,  6,  and  T,  are  removed  on  a 


Fig.  169. — Inferior  Combined   Root   Incising,  Separating,  and  Ele- 
vating Forceps.    (Dr.  T.  C.  Stellwagen's  Pattern.) 


common  principle.  The  first  attempt  is  to  be  made  with  the  ele- 
vator: laying  the  groove  of  this  instrument  clo.sely  against  the  root, 
its  sharpened  knifelike  edge  is  insinuated  between  the  fang  and  pro- 


416 


ORAL   DISEASES  AND   SURGERY. 


cess,  being  worked  down  as  far  as  possible.  The  handle  is  now 
carried  obliquely  to  the  line  of  the  root,  and  thus,  with  a  careful 
oscillatory  motion,  the  piece  is  forced  from  its  bed.  It  is  very  well 
known,  however,  that  with  a  dense,  heavy,  alveolar  process,  this 
instrument  cannot  be  made  to  operate  so  happil}^  it  being  next  to 

Fig.   170. — Superior   Combined  Eoot  Incising,  Separating,  and  Ele- 
vating Forceps.     (Dr.  T.  C.  Stellwagen's  Pattern.) 


impossible  to  insinuate  it  between  the  lione  and  tooth.  Under  these 
circumstances,  another  instrument,  the  screw  (Fig.  171),  may  be 
brought  into  requisition. 


Fig.  171.— The  Screw. 


The  screw  is  designed  to  operate  upon  the  tooth  root  as  the  spiral 
operates  upon  the  cork.  Well  tempered,  and  very  sharp,  it  is  intro- 
duced into  the  pulp  canal,  and  quietly  and  gently  turned  until  it  has 
taken  a  firm  hold.  A  simple  direct  movement,  and  the  root  is  brought 
away. 

It  may  happen,  however,  that  no  hold  sufficiently  firm  for  the 
extraction  can  be  obtained  with  this  instrument.  When  this  is  the 
case,  it  may  be  laid  aside,  and  the  always  reliable  cutting  forceps 
brought  into  requisition.  If  preferred,  however,  the  screw  can  be 
bored  into  the  tooth  until  fracture  is  produced,  and  this  will  some- 
times enable  us  quite  easily  to  pick  away  the  splinters:  particularly 
will  this  be  found  to  be  the  case  when  the  line  of  the  fracture  divides 


THE  EXTBACTION  OF  TEETH. 


417 


the  root  in  its  length.  The  forceps  known  as  Dubs'  and  HuUihen's 
represent  the  combination  of  the  screw  with  the  forceps.  In  the 
Hullihen  instrument  the  screw  is  designed  more  especially  to  aflFord 
support,  preventing  the  blades  from  crushing  the  root.  In  the  Dubs' 
forceps  the  spring  trigger  corresponds  with  the  two  forces,  affording 
thus  not  only  support,  but  allowing  the  extracting  force  to  be  divided 
between  the  two  means. 

In  using  these  instruments  (their  employment  being  confined  to 
the  single-root  teeth),  the  shank  holding  the  screw  is  to  be  confined 
in  the  grasp  of  the  blades,  and,  thus  controlled,  it  is  to  be  screwed 
into  the  pulp  cavity  :  a  proper  hold  secured,  the  blades  are  to  be 
expanded,  and  thrust,  as  in  the  ordinary  application,  about  the  root, 
which  is  then  extracted  secundum  artem. 

In  many  instances,  however,  the  immediate  employment  of  the 
screw  is  found  impracticable,  owing  to  the  shape  of  the  canal  or  the 

Fig.  172. — Dub.s'  Screw  Forceps. 


1,  conical  screw  with  square  ratcliet  shaft;  2,  beaks  of  forceps,  grooved  inside;  3, 
socket  with  square  hole  to  receive  shaft ;  i,  spring  trigger  by  which  the  screw  cau 
be  detached  at  pleasure  at  any  given  point. 


Fig.  173. — Hullihen's  Screw  Forceps. 


density  of  the  dentine :  in  these  cases  the  fang  is  first  to  be  reamed 
out,  which  manipulation  is  accomplished  without  effort  by  the  use 
of  drills. 

Roots  of  the  molar  and  wisdom  teeth,  superior  and  inferior,  are 
removed  on  a  common  principle.  In  the  use  of  the  elevator,  a  very 
happy  result  is  not  unfrequently  secured  by  applying  the  blade  to 

27 


418 


ORAL  DISEASES  AND  SURGERY. 


the  inner  face  of  the  root,  carrying  the  shank  across  the  mouth,  and 
making  a  fulcrum  of  some  convenient  opposite  tooth. 

Where  the  roots  of  a  molar  tooth  are  so  firmly  fixed  as  to  seem 
incapable  of  removal  with  the  application  of  an  ordinary  amount  of 
force,  it  is  better  to  divide  them.  This  is  easily  done  with  the 
cutting  forceps,  and  after  the  separation  each  root  may  be  picked 
out  singly,  and  generally  with  comparative  ease. 

Fig.   174. — XJpi'Er  Front   Root,  Si'kaight. 


Fig.  175 — Upper  and  Loavkr  PiOot,  Hatf  Curvi:t). 


Fig.  176  — Ldwkr  Hoot,  Full  Cuuvkd. 


Fig.   177. — Upper  Back  Eoot  (universal 


Forceps  of  delicate  beak  are  much  in  favor  for  the  extraction  of 
roots- of  teeth:  indeed,  it  is  a  common  practice  to  exhaust  their 
capability  before  resorting  to  other  means.  Figs.  174  to  180  exhibit 
different  forms  of  such  forceps.  Figs.  177  and  178  are  to  have  the 
preference, — these  being  quite  capable  of  performing  the  work  of 
the  others. 


THE  EXTB ACTION  OF  TEETH. 
Fig.  178. — Bayonet-shape  Eoot. 


419 


Fig.  179. — Half  Curved,  Long  Beak,  Alveolus. 


Fig.  180. — Lower  Molar  Eoot  (with  Croavns). 


I 


Deformed  or  Anomalous  Teeth. — Understanding  the  principles 
on  which  teeth  of  ordinary  character  are  extracted,  the  practitioner 
will  need  but  little  instruction  so  far  as  anomalies  are  concerned. 

In  Fig.  181,  Subfigures  1,  2,  3,  4,  and  5,  although  so  ill  portrayed 
by  the  artist,  sufficiently  represent  five  anomalies,  and  these  may  very 

Fig.  181. 


well  stand  for  the  class.  In  removing  such  teeth  from  the  mouth,  the 
matter  of  greatest  importance  is  to  recognize  them.  Now,  while 
this  cannot  in  all  cases  be  done  so  as  to  appreciate  exactly  the  con- 
dition of  the  roots,  yet  we  may  always  say  that  some  impediment 
to  the  removal  exists  ;    and  this,  after  all,  is  the  most  important 


420  ORAL  DISEASES  AND  SURGERY. 

matter,  as  it  influences  the  amount  of  force  exhibited,  which,  too 
freely  rendered,  might  result  in  fracture  of  the  bone,  or  still  greater 
injury  to  surrounding  parts. 

A  tooth,  as  represented  in  Subfig.  1  (the  first  to  the  left),  will 
generally  yield  in  its  roots  so  as  to  pass  the  intermediate  piece  of 
process.  If  it  does  not  so  yield,  then  this  wedge  of  bone  will  frac- 
ture and  be  brought  away.  Such  fracture,  however,  results  in  no 
harm,  and  is  to  be  deemed  of  little  consequence. 

Subfig.  2,  by  the  great  curve  in  the  root,  is  made  incapable  of 
passage,  unless,  after  being  loosened,  it  is  carried  outward  in  the 
direction  of  the  axis  of  the  curve.  In  this  way  it  is  easily  removed. 
The  character  of  the  curve  is  recognized  by  the  resistance  ofl'ered 
when  the  tooth  is  carried  in  certain  positions,  and  by  the  absence  of 
such  resistance  when  it  is  carried  in  the  proper  line.  The  attempt 
to  remove  such  a  tooth  by  simple  force  would  result  either  in  frac- 
ture at  the  curve,  in  lifting  out  a  neighboring  tooth,  or  in  fracture 
more  or  less  extensive  of  the  alveolar  process. 

Subfig.  3  represents  exostosis  of  a  root.  A  tooth  fang  so  enlarged 
will  not  pass  through  the  process  unless  the  bone  is  very  open  in  its 
structure.  Such  a  tooth  may  be  made  quite  loose,  but,  while  it 
moves  freely  enough  in  its  socket,  it  is  felt  to  be  held  by  something 
abnormal.  To  free  such  a  tooth,  it  is  only  necessary  to  use  the 
cutting  forceps,  or,  what  I  prefer,  to  take  the  ordinary  small  surgical 
chisel  and  cut  away  sufiicient  of  the  process  to  admit  of  the  passage. 
This  little  operation  is  easy  of  accomplishment,  and  must  prove 
adequate  to  the  end. 

Subfig.  4  represents  a  form  of  twin  teeth.  The  two  must  be 
extracted  together,  which  may  be  difficult  or  the  reverse,  accord- 
ing to  the  character  of  the  process.  It  is  well,  before  making  the 
effort  to  extract,  to  free  the  process  from  the  teeth  as  thoroughly  as 
possible:  this  is  done'by  a  sharp  and  flat  elevator  or  the  chisel. 

Subfig.  5  represents  a  second  form  of  twin  growth,  the  result  of 
original  germ  union.  If  the  offshooting  bulb  is  situated  within 
and  covered  by  the  process,  it  is  to  be  treated  as  if  it  were  a  case  of 
exostosis  of  the  fang.  These  germ  unions  are  exceedingly  rare,  and 
one  might  not  be  met  with  in  a  lifetime. 

Among  other  curious  examples  of  anomalous  teeth  to  be  seen  in 
the  Philadelphia  Dental  College  are  those  exhibited  on  the  succeed- 
ing page.  Referring  to  the  conjoined  molars,  the  gentleman  who 
presented  the  specimens  remarks  : 

"  The  practical  feature  in  this  case  concerned  the  extraction.  This 


I 


THE  EXTRACTION  OF  TEETH.  421 

was  effected  with  less  trouble  than  might  be  supposed.  In  the  attempt 
to  extract  the  second  molar,  it  soon  appeared  that  there  was  some- 
thing wrong,  and  the  effort  to  remove  it  was  suspended,  and  a 

Fig.  182.  Fig.  183. 


thorough  examination  made.  In  the  second  attempt,  the  force  was 
very  cautiously  applied,  to  find  what  direction  the  tooth  would 
take.  It  yielded  most  to  an  inward  motion,  and  by  a  continued 
effort  in  that  direction  the  removal  was  effected  with  only  a  slight 
fracture  of  the  lingual  border  of  the  alveolus." 

The  second  specimen  is  a  union  of  three  of  the  anterior  teeth. 


CHAPTER    XYII. 

GENERAL   REMARKS   ON   EXTRACTION. 

The  relationship  of  the  teeth  with  the  jaws  is  through  the  medium 
of  a  cellular  process  known  as  the  alveolar.  Each  tooth  is  lodged 
in  pits  or  alveoli  corresponding  to  the  number  and  character  of  its 
roots:  thus,  the  central  and  lateral  incisors,  the  cuspidati,  and  the 
bicuspidati,  having  each  but  one  root,  have  each  but  one  alveolus. 

The  molar  teeth  of  the  superior  jaw  have  three  roots,  conse- 
quently a  threefold  relation  to  the  alveolar  process. 

The  molar  teeth  of  the  inferior  jaw  have  two  roots  and  two  al- 
veoli. 

The  wisdom-teeth,  as  a  rule,  have  a  single  short  curved  and 
stumpy  root,  consequently  a  similar  alveolus. 

The  association  of  the  teeth  with  their  alveoli  is  through  the 
medium  of  a  fibro-cellular  tissue  ;  this  membrane  is  coarse  and  resist- 
ing about  the  free  edge  of  the  bone,  loose  and  cellular  as  it  gets  deeper. 
A  properly-shaped  lancet  may  be  made  to  excise  the  coarse  fibres ; 
consequently,  the  operation  of  extraction  should  always  be  preceded 
by  that  of  thorough  lancing.  In  this  way  much  of  the  strength  of 
the  relationship  of  the  tooth  with  its  socket  is  to  be  overcome. 

A  tooth  extracts  with  difBculty  or  with  ease  as  influenced  by  the 
character  of  its  periodonteum,  and  the  loose  or  firm  structure  of  its 
alveolus. 

A  limited  fracture  of  the  alveolar  process  is  generally  not  to  be 
considered  a  matter  of  much  consequence.  If  an  extensive  fracture 
should  associate  with  an  extraction,  the  tooth  and  bone  may  be  laid 
carefully  back  in  place,  and  treated  as  any  common  fracture;  or,  if 
this  does  not  seem  desirable,  the  fractured  piece  may  be  dissected 
from  the  soft  parts,  and  the  wound  treated  on  general  principles. 
Sometimes,  when  too  much  force  is  injudiciously  used,  a  fracture 
may  occur,  including  several  teeth.  In  such  accident,  the  circum- 
stances of  each  particular  case  must  direct  the  practitioner ;  they  are 
ugly  and  generally  unnecessary  troubles,  and  not  apt  to  occur  where 
proper  care  is  exercised.  Meeting  myself  with  such  an  accident,  I 
(422) 


GENERAL  REMARKS   ON  EXTRACTION.  423 

should  certainly  make  a  first  effort  to  reunite  the  parts ;  failing  in 
which,  I  would  have,  of  course,  no  resource  but  to  dissect  away  the 
piece,  or  otherwise  wait  on  nature  for  a  process  of  exfoliation. 

Laceration  of  the  gums  is  an  accident  frequently  associated  with 
the  careless  extraction  of  teeth.  Such  laceration  may  be  trifling  or 
it  may  be  serious,  and  is,  perhaps,  always  to  be  guarded  against  by 
proper  attention  to  lancing.  A  small  piece  of  gum  torn  by  a  tooth 
as  it  comes  away  had  better  be  removed  ;  left  in  the  mouth,  it  is 
a  source  of  annoyance,  and  reflects,  in  the  mind  of  the  patient, 
on  the  practitioner.  Large  strips  are  to  be  carefully  laid  back  in 
place,  and  secured  by  one  or  more  stitches,  or  other  convenient 
means  of  retention. 

Hemorrhage. — Hemorrhage  after  extraction  is  influenced  by  two 
circumstances :  the  state  of  the  parts,  and  the  predisposition  of  the 
patient.  An  ordinary  tooth  extraction  is  followed  by  hemorrhage 
lasting  but  a  very  few  minutes.  In  extraction  for  periodonteal  trouble 
the  bleeding  is  more  profuse.  Such  hemorrhage,  however,  if  at  all 
reasonable,  is  not  to  be  interfered  with  ;  it  expedites  the  cure  of  the 
case  wonderfully,  relieving  the  general  congestion  of  the  parts. 

.  Undue  hemorrhage  of  local  signification  is  found  to  depend  either 
on  non-contractility  in  the  foraminal  and  circumferential  vessels,  or 
on  excessive  vascularity  in  the  alveolar  walls.  Where  the  bleeding 
is  from  an  ai'tery,  it  will  be  more  or  less  per  saltern;  where  venous 
or  capillary,  it  will  be  continuous.  Hemorrhage  of  constitutional 
expression  is  associated  with  the  defibrinating  condition,  or  with 
hereditary  predisposition.  Anaemia  as  a  cause  is  perhaps  the  most 
common  of  the  systemic  vices  ;  next  to  this  may  be  ranked  a  typhoid 
state  ;  after  this,  purpura.  Plethora  conjoined  with  laxity  of  the 
tissues  is  another  of  the  constitutional  causes.  Vicarious  relation- 
ship is  a  condition  sometimes  met  with. 

In  cases  where  a  hemorrhagic  diathesis  exists,  alveolar  hemor- 
rhage is  not  unfrequeutly  of  the  most  profuse  character,  making 
necessary  the  most  judicious  and  energetic  treatment  for  its  arresta- 
tion.  Two  cases,  occurring  with  the  author  in  the  persons  of  a 
father  and  son,  may  illustrate  such  direction  of  practice. 

Mr.  B.,  aged  19,  applied  to  his  dentist  for  the  removal  of  the 
second  superior  molar  of  the  right  side.  The  operation  over,  the 
bleeding  seemed  not  excessive,  and  the  patient  was  dismissed  as 
usual.  On  the  same  day,  in  the  latter  part  of  the  afternoon,  bleed- 
ing recommenced ;  Monsel's  solution  of  the  persulphate  of  iron  was 
employed,  and  the  patient  again  dismissed.     During  the  night  hem- 


424  ORAL   DISEASES  AND   SURGERY. 

orrhage  again  recurred,  and  the  family  physician  was  sent  for ;  the 
solution  of  iron  was  again  employed,  and  a  temporary  arrest  again 
secured.  The  next  day  it  reappeared,  and  nitrate  of  silver  was 
applied  in  the  alveolus.  This  controlled  the  hemorrhage  until  the 
succeeding  day,  when  it  again  appeared ;  and  so  off  and  on  over  a 
period  of  eight  days.  At  this  time  I  first  saw  the  case  in  consulta- 
tion, the  patient  being  unable  to  swallow  any  other  than  liquid  food, 
owing  to  the  swelling  of  the  fauces  and  oesophagus  from  the  effects 
of  an  over-free  use  of  the  nitrate  of  silver. 

In  examining  the  case,  we  first  took  from  the  cavity  the  half- 
coagulated  clot  it  contained,  and,  washing  the  parts  thoroughly, 
discovered  that  the  bleeding  came  not  alone  from  the  socket  of  the 
tooth,  but  fi'om  about  the  margins  which  had  been  ulcerated  and 
degraded  by  the  various  applications.  Hemorrhage  was  entirely 
capillary. 

In  a  treatment  which  resulted  in  the  immediate  control  of  this  case, 
the  following  course  was  pursued.    First,  an  impression  in  wax  was 
taken  of  the  roof  of  the  mouth,  inclusive  of  the  bleeding  part.    From 
this  impression  a  model  was  made,  to  which  was  struck  a  silver 
plate.     This  accomplished,  which  consumed  about  two  hours,  the 
bleeding  cavity  was  packed  with  alum-saturated  lint,  the  lint  pro- 
jecting and  overlying  the  ulcerated  margin.     Over  and  upon  this 
was  now  placed  the  accurately  fitting  and  compressing  plate.    Upon 
the  plate,  raised  to  the  common  level  of  the  adjacent  teeth,  was  laid 
a  fold  of  linen  :  the  lower  jaw  was  next  closed  upon  this  compress 
and  kept  in  position  by  a  bandage.     Tincture  of  Erigeron  Canadensis 
was  administered,  and  the  feet  of  the  patient  were  placed  in  hot  water. 
Hemorrhage  ceased  entirely  in  the  course  of  an  hour,  and  did  not  recur. 
Mr.  B.,  the  father  of  this  young  gentleman,  aged  perhaps  50,  suf- 
fered five  days  from  hemorrhage,  under  the  following  circumstances  : 
A  wisdom-tooth  of  the  left  upper  jaw  troubling  him  because  of  its 
great  looseness,  he  applied  to  his  dentist  for  its  removal.      Not 
deeming  it  necessary  or  desirable  to  wound  the  gum,  the  practitioner 
extracted  the  tooth  without  the  preliminary  step  of  lancing,  and  in  the 
act  was  so  unfortunate  as  to  tear  away  a  small  strip.     Hemorrhage 
was  immediate,  and  more  or  less  continuous.  MonsePs  solution  being 
prescribed  by  his  physician,  it  was  employed,  but  with  somewhat 
the  same  result  as  in  the  son's  case.     On  the  evening  of  the  fifth 
day  I  first  saw  this  case.     The  patient  was  much  weakened  from 
the  excessive  discharge,  and  exceedingly  frightened  and  nervous. 
Washing  away  the  clots,  I  discovered  the  blood  oozing  from  the 


1 


GENERAL  REMARKS   ON  EXTRACTION.  425 

torn  gum,  and  not  at  all  from  the  tooth-socket.  I  commenced  imme- 
diately to  give  erigeron  in  drop  doses,  repeated  every  minute,  and 
ligated  against  the  wound  a  tuft  of  alum-saturated  cotton.  The 
hemorrhage  ceased  entirely  within  ten  minutes,  and  did  not  recur. 
As  an  assurance,  I  prescribed  the  wine  of  iron,  which  the  patient 
continued  to  take  to  the  amount  of  four  ounces. 

Tincture  of  Erigeron  Canadensis,  in  cases  of  this  character,  seems 
to  be  a  quite  reliable  haemostatic;  not  entirely  so,  however,  as  I  have 
prescribed  it  where  it  certainly  failed  to  exert  the  slightest  influence. 

Hemorrhage  dependent  on  the  typhoid  condition  is  to  be  treated 
with  most  success  by  conjoining  with  the  local  medication  the 
internal  administration  of  acids,  than  which  none  seems  to  answer 
so  good  and  reliable  a  purpose  as  the  dilute  hydrochloric.  Purpura, 
as  a  predisposition,  demands  its  own  peculiar  class  of  remedies. 
Anaemia  is  best  treated  for  immediate  ends  with  the  tincture  of 
the  chloride  of  iron.  Vicarious  hemorrhage  requires  an  attention 
which  shall  dispose  to  the  restoration  of  the  lost  harmony.  What- 
ever the  systemic  vice,  appreciation  of  the  requirements  and  the 
meeting  of  the  indications  constitute  a  most  important  direction  in 
the  treatment. 

Depressing  the  action  of  the  heart  is,  under  almost  all  circum- 
stances, a  most  valuable  means  for  the  arrestation  of  hemorrhage. 
To  this  end  the  tincture  of  veratrum  viride  is  alwaj^s  to  be  given 
with  satisfaction.  Conjoined  with  this,  and  indeed  in  many  instances 
quite  capable  of  taking  its  place,  is  the  hot  foot-bath, — the  impres- 
sion to  be  continued  until  the  patient  shall  either  grow  faint  or  break 
out  into  profuse  perspiration. 

Lead  and  opium  prescribed  in  conjunction  form  a  very  reliable 
hemostatic  ;  two  grains  of  the  first  to  one  of  the  latter  may  be  given 
every  two  or  four  hours,  according  to  the  urgency  of  the  case. 

Rest  is  one  of  the  reliable  means  of  cure.  A  patient  is  to  be  kept 
quiet,  both  as  the  body  and  the  mind  are  concerned. 

The  local  treatment  of  dental  hemorrhage  has  the  threefold  signifi- 
cation of  mechanical,  vital,  and  chemical.  The  first  considers  means 
which,  through  compression  or  clot,  shall  confine  the  blood  to  its 
vessels.  Plugging  the  alveolus  is  a  common  practice  in  this  direc- 
tion. A  plug  may  be  made  of  almost  any  convenient  material ; 
common  raw  cotton,  or  shreds  of  lint  made  by  scraping  linen, 
answer  commonly  every  purpose.  When  hemorrhage  is  per  saltern, 
a  splint  of  soft  pine  wood,  shaved  to  a  point  corresponding  with  the 
apex  of  the  alveolus,  being  carried  and  retained  in  place,  will  almost 


426  ORAL  DISEASES  AND  SURGERY. 

of  a  certainty  control  the  hemorrhage.  Plates  of  metal  or  gutta- 
percha, moulded  so  as  accurately  to  close  the  cavity,  thus  favoring 
the  formation  of  a  clot,  are  frequently  employed  with  success. 
Spider-web  as  a  clot-holder  is  another  means,  the  web  being  packed 
into  the  cavity  and  there  retained.  Compressed  sponge  is  still 
another  of  the  mechanical  means.  This,  when  thoroughly  coated 
with  wax  and  of  delicate  point,  may  be  carried  to  the  very  apex  of 
a  cavity,  and,  when  forced  into  itself  dnd  maintained  in  position  l)y 
an  overlying  compress,  constitutes  one  of  the  most  reliable  of  this 
character  of  agents. 

Of  the  medicinal  agents  having  the  signification  of  forming  a  clot, 
preference  is  to  be  given  to  tannic  acid.  The  persulphate  of  iron,  a 
preparation  much  used  in  general  practice,  is  to  be  denied  applica- 
tion in  the  mouth.  Without  doubt  a  clot  is  to  be  formed  more 
speedily  and  solidly  with  this  agent  than  with  the  tannin,  but  the 
dianger  from  secondary  hemorrhage  overbalances  all  its  virtues.  A 
tannin  clot  is  not  soluble  by  the  blood,  and  needs  but  support  to 
possess  all  required  virtues. 

Of  the  astringents  and  stimulants,  acting  by  exciting  responsive 
force  in  the  tissues  to  which  they  are  applied,  and  controlling  hem- 
orrhage through  contractility,  we  have  alum,  zinc,  lead,  capsicum, 
iodine,  turpentine,  and  most  of  the  mineral  acids. 

Alum  in  full  saturation  with  water  is  one  of  the  most  reliable  of 
the  haemostatics,  and,  when  properly  supported  by  a  mechanical 
adjunct,  it  will  seldom  be  found  to  fail. 

Of  agents  acting  chemically  to  the  control  of  hemorrhage,  mention 
may  be  made  of  catechu  and  kino  among  the  vegetables,  and  nitrate 
of  silver  among  the  metals;  the  latter,  however,  is  an  objectionable 
preparation,  because  of  the  destruction  of  tissue  so  common  to  its 
emplo3'ment,  except  when  used  in  dilution. 

All  ordinary  means  failing  for  the  control  of  an  alveolar  hemor- 
rhage, the  actual  cautery  may  be  applied.  A  control  thus  secured, 
however,  is  to  be  seconde'd  by  the  anti-hemorrhagics  of  internal 
expression,  as  it  is  frequently  found  to  be  the  case  that  the  separation 
of  the  slough  re-excites  the  original  trouble. 

Compression  made  to  a  bleeding  alveolus  should  be  moderate, 
not  severe ;  and  when  made,  and  the  hemorrhage  has  been  con- 
trolled thereby,  it  should  not  be  too  hastily  removed. 

Luxation  of  the  Inferior  Maxilla. — Occasionally,  as  the 
result  of  a  sudden  movement,  or  an  abnormal  laxity  of  the  ligaments 
of  the  temporo-maxillary  articulation,  the  condyloid   process  falls 


GENERAL  REMARKS  ON  EXTRACTION.  427 

forward  over  its  glenoid  boundary.  The  patient  is  thus  rendered 
unable  to  close  the  mouth,  and  is  said  to  labor  under  luxation.  (See 
chapter  on  Luxaiion.) 

Local  Anesthetics  in  the  Extraction  of  Teeth. — The  em- 
ployment of  various  local  agents  to  secure  exemption  from  pain  in 
the  operation  of  extraction  has  of  late  commanded  so  much  atten- 
tion that  no  chapter  treating  of  such  operations  would  be  complete 
without  reference  to  the  subject. 

The  most  simple  and,  we  may  say,  elementary  application  in  this 
direction  consists  in  inclosing  in  a  piece  of  bladder,  or  other  conve- 
nient skin,  a  small  portion  of  pounded  ice  and  salt,  and  enveloping, 
for  a  few  moments,  the  part  to  be  operated  on.  To  secure  most 
conveniently  the  effect  of  such  a  process  of  refrigeration,  various 
instruments  have  been  devised,  but  none,  so  far  as  the  application 
of  the  ice  and  salt  is  concerned,  have  been  found  to  answer  any 
better  purpose  than  the  bladder  or  skin  inclosure.  Such  skins 
should  consist  of  two  little  bags,  one  to  rest  upon  the  outer,  the 
other  upon  the  inner,  side  of  the  gum.  To  prevent  pain  from  the 
application  of  the  cold,  the  bags  should  be  brought  gradually  in 
contact  with  the  gums ;  or,  what  will  answer  a  similar  purpose,  the 
application  may  be  preceded  by  ice-cold  water  held  in  the  mouth  for' 
a  few  moments. 

An  apparatus  designed  and  manufactured  by  Messrs.  Home  & 
Thornwaite,  of  London,  is  said  to  answer  a  very  good  purpose,  and 
is  thus  described : 

"A  required  amount  of  water  is  cooled  down,  by  means  of  ice  and 
salt,  to  about  zero,  in  a  vessel  called  a  refrigerator.  To  this  vessel 
is  attached  another,  called  a  graduator,  containing  warm  water  at 
about  100°,  and  so  constructed  as  to  allow  the  slow  admixture  of  its 
contents  with  the  chilled  water  in  the  refrigerator,  and  thus  produce' 
a  gradually  diminishing  temperature,  for  the  purpose  of  preventing 
sudden  shock  and  pain  to  the  teeth,  which  a  direct  application  of 
cold  would  inevitably  cause.  A  tube  conveys  this  graduated  cur- 
rent into  a  terminal  portion  constructed  of  very  fine  membrane, 
which  adapts  itself  to  the  form  of  the  gums,  and  wholly  surrounds 
the  tooth  to  be  extracted.  The  fluid  then  passes  away  through  an 
exit  tube.  In  this  manner  a  constant  current  of  cold,  at  a  decreasing 
temperature,  is  made  to  pass  over  the  part,  abstracting  therefrom 
all  heat,  and  consequently  all  feeling." 

The  concentrated  tincture  of  aconite  is  a  useful  local  anaesthetic, 
but  one  that  should  be  used  with  a  considerable  degree  of  caution. 


428  OBAL  DISEASES  AND  SURGERY. 

If  a  portion  of  this  tincture  be  applied  to  one-half  the  lip,  sensibility 
will  be  so  interfered  with  that  a  goblet  placed  to  the  parts  will 
appear  as  if  broken. 

A  mixture  of  chloroform  and  laudanum  in  equal  parts  is  much 
lauded  by  some.  To  apply  this,  it  is  only  necessary  to  saturate  a 
tuft  of  cotton  and  lay  it  against  the  tooth  to  be  extracted. 

Another  means,  serving  to  attract  the  attention  of  the  patient 
from  the  operation,  consists  in  painting  the  gum  heavily  with  tinc- 
ture of  iodine.  After  such  painting,  people  will  often  be  found  to 
say  that  the  pain  has  been  much  ameliorated. 

Electro-galvanism  claimed  at  one  time  a  good  share  of  attention. 
Its  application  consists  in  applying  one  pole  of  a  battery  to  the  for- 
ceps, while  the  other  is  held  in  the  hand  of  the  patient;  a  gentle 
current  is  then  to  be  let  on,  during  the  passage  of  which  the  tooth 
is  extracted.  This  mode  of  effecting  local  anaesthesia  is  still  prac- 
ticed by  very  many;  but  I  must  say  that,  in  my  hands  and  in  the 
hands  of  many  experienced  friends,  it  has  proved  a  failure.  Not 
that  it  is  to  be  denied  that  in  certain  cases  it  does  seem  somewhat 
to  obtund  sensibility,  but  in  the  majority  of  instances  it  either  does 
no  good  at  all,  or  adds  the  discomfort  of  the  current  to  the  pain 
of  the  operation. 

The  application  of  the  spray  of  ether  or  of  rhigolene  is  the  latest, 
and  perhaps  the  most  worthy  and  reliable,  of  the  local  anaesthetics ; 
certainly  one  may  say  reliable  when  employed  for  operations  of 
limited  extent  about  the  soft  parts,  but  as  to  an  equal  availability 
in  tooth  extraction,  my  experience  has  not  so  well  satisfied  me. 
With  these  agents  as  thus  locally  applied  I  have  performed  many 
incisions,  in  the  way  of  the  removal  of  sebaceous  and  other  super- 
ficial tumors,  the  opening  of  abscesses,  carbuncles,  and  similar 
operations,  and  the  result  has  been  everything  I  could  have  desired ; 
but  in  their  application  to  the  teeth,  the  obtunding  of  the  sensibility 
has  not  by  any  means  been  so  marked ;  and  particularly  has  this 
been' the  case  where  rhigolene  was  used. 

The  process  of  freezing  a  part  through  the  known  refrigerant 
power  of  evaporating  ether  seems  first  to  have  suggested  itself  to 
Dr.  Richardson,  of  London.  An  instrument  invented  by  this  gentle- 
man for  the  accomplishment  of  such  an  end  is  here  exhibited,  forms 
of  bellows  for  both  hand  and  foot  being  represented. 

For  the  spraying  of  any  plain  surface,  the  simple  straight  tube  is 
all  that  is  necessary.  For  the  teeth,  the  double  sprayer,  as  seen  in 
the  drawing,  is  used ;  with  this  instrument  a  continuous  vapor  is 


GENERAL  REMARKS  ON  EXTRACTION.  429 

cast  both  upon  the  outer  and  the  inner  face  of  the  gum,  and  congela- 
tion is  rapidly  induced. 

Fig.  184.— Spray  Apparatus— Hand-Ikstrttment. 


In  using  this  hand-instrument,  the  operator  himself  should  not 
work  the  pump.  A  very  few  moments'  compression  of  the  ball 
renders  the  hand  shaky  and  unmanageable. 

Upon  this  instrument  of  Dr.  Richardson's  many  modifications 
have  already  been  made.  Of  these,  one  by  Messrs.  Codman  and 
Shurtlefif,  of  Boston,  has  perhaps  attracted  most  attention.  It  cer- 
tainly seems  to  divide  the  ether  more  Infinitesimally,  thus  insuring 
a  more  complete  vaporization ;  but  it  has  a  weak  point,  in  that  the 
tube  seems  frequently  to  freeze  or  choke  up,  an  accident  that  does 
not  occur  with  Dr.  Richardson's  instrument. 


An  objection  urged  to  the  use  of  extreme  cold  as  thus  induced  is 
that  injury  is  done  to  the  soft  parts,  as  it  is  thought  will  be  mani- 
fested in  inability  to  unite  wounds  happily  and  easily.  That  such 
objection  is,  however,  not  valid,  I  have  satisfactorily  proven;  for,  if 
anything,  parts  thus  operated  on  have  united  better  and  with  less 
inflammatory  reaction  than  has  obtained  where  the  spray  has  not 
been  used. 


430 


ORAL  DISEASES  AND  SURGERY. 


Rhigolene  or  hydrocarbon,  manufactured  from  coal-oil,  and  much 
vaunted  by  some,  has  not,  in  my  hands,  proven  so  satisfactory  as 

Fig.  185.— Spray  Apparatus— Foot-Instrument. 


ether.  It  certainly  freezes  a  part  more  quickly  than  this  latter 
agent,  but  this  does  not  seem  alone  to  be  the  object,  as  anaesthesia 
IS  not  nearly  so  complete. 


CHAPTER    XV  1 11. 


GENERAL    ANESTHESIA, 


"  So  long  as  pain  is  an  evil  and  ease  a  good — so  long,  in  other 
words,  as  man  is  man — must  any  means  be  prized  that  is  capable 
of  achieving  the  latter  by  the  abolition  of  the  former.  As,  then,  the 
pain  of  surgical  operations  is  certainly  of  the  most  terrible  of  its 
class,  and  it  is  no  matter  of  doubt  that  agents  exist  which  possess 
the  power  of  abolishing  this  pain,  what  remains  for  consideration 
is  not  so  much  whether  tliis  means  shall  be  hailed  as  a  matchless 
and  priceless  discovery,  and  be  cherished  and  adopted  as  a  blessed 
thing, — this  appreciation  has  been  made,  this  adoption  has  been 
consecrated  by  almost  universal  practice:  what  remains  for  con- 
sideration is,  whether  the  good  is  a  pure  good,  or  is  counterbalanced 
by  evil. 

"  The  obvious,  open,  palpable,  glorious  good  of  anaesthesia,  and 
particularly  ether  anaesthesia,  is  to  deliver  the  wretched  victim  of 
surgical  disease  from  the  additional  torture  of  pain  while  seeking 
the  goal  of  health  through  the  portals  of  chirurgery.  The  evils 
that  have  been  said  to  follow  or  accompany  this  good  have,  how- 
ever, been  regarded  by  some  as  of  so  serious  a  character  as  not  only 
to  induce  them  to  reject  general  anaesthesia  in  their  own  practice, 
but  to  denounce  it  publicly  as  a  means  that  should  not  obtain  with 
scientific  and  conscientious  men. 

"  We  confess  that  we  are  surprised  whenever  we  hear  these 
expressions;  and,  strange  as  it  may  seem,  there  are  even  now 
enough  to  give  expression  to  them.  Of  the  hundreds  and  thousands 
— we  might  say  hundreds  of  thousands — who  have  taken  ether  to 
insensibility,  we  have  been  unable  to  discover,  after  the  most  ex- 
tended inquiries,  a  single  case  which  resulted  in  death,  or  left  behind 
it  consequences  of  serious  importance  that  were  certainly  attributable 
to  it.  In  a  small  proportion  of  cases  there  have,  no  doubt,  been 
some  unpleasant  results,  such  as  temporary  depression  of  the  vital 
powers ;  headache,  more  or  less  considerable,  for  some  hours,  or 
even  days ;  hysterical  excitement  in  women  for  a  similar  length  of 

(431) 


432  ORAL  DISEASES  AND  SURGERY. 

time ;  slight  bronchial  irritation,  nausea,  and  sickness,  and  some 
other  slight  affections ;  but  the  proportion  of  patients  suffering, 
even  in  this  slight  manner,  has  been  extremely  small, — indeed,  won- 
derfully small,  when  we  consider  the  indiscriminate  manner  in  which 
the  practice  has  been  had  recourse  to,  with  bad  ether  and  bad 
manipulators.  Indeed,  that  so  very  few  and  such  trifling  accidents 
have  occurred  in  such  a  state  of  things,  is  most  convincing  proof  of 
the  general  safety  of  the  practice.  For,  in  considering  the  entire 
incompetence  of  the  many  who  are  in  daily,  fearless  employment  of 
the  agent,  so  far  from  these  uniformly  innocent  results  being  antici- 
pated, one  might  very  naturally  look  for  others  of  a  very  different 
kind.  We  have  ourselves  been  constantly  looking  for  ill  conse- 
quences, and  we  are  still  prepared  to  find  them;  but  when  thy 
arrive,  if  ever  they  now  are  to  arrive,  we  shall  have  to  consider 
well,  before  condemning  the  agent,  whether  the  event  was  a  neces- 
sary consequence  of  its  use,  or  merely  an  accidental  result  from  its 
abuse." 

The  preceding  very  impartial  and  terse  consideration  of  the  gen- 
eral question  of  anaesthesia,  as  reference  is  had  to  its  production  by 
sulphuric  ether,  we  find  in  a  British  monograph.  The  question,  "  To 
what  are  accidents  (if  accidents  there  are)  attributable  ?"  is  naturally 
suggested,  and  would  excite  in  the  mind  a  desire  to  enter  on  the 
consideration  of  a  subject  fraught  with  such  importance,  before 
taking  up  its  use  or  joining  in  the  cry  of  those  who  abuse. 

Such  consideration  I  propose  to  make  the  subject  of  this  chapter, 
and  trust  that  not  a  little  personal  experience  enjoyed  will  enable 
me  to  present  it  with  some  degree  of  clearness.  We  first  consider 
sulphuric  ether. 

An  agent,  refreshing  in  itself,  may,  in  improper  hands,  become  a 
source  of  ill :  this  truth  applies  to  the  whole  Materia  Medica. 

What  is  sulphuric  ether  ? 

"When  equal  weights  of  rectified  spirits  and  oil  of  vitriol  are 
mixed  in  a  retort,  the  latter  connected  with  a  good  condensing 
arrangement,  and  the  liquid  heated  to  ebullition,  a  colorless  and 
highly-volatile  liquid,  long  known  under  the  name  of  ether,  or 
sulphuric  ether,  distills  over.  The  process  must  be  stopped  as  soon 
as  the  contents  of  the  retort  blacken  and  froth,  otherwise  the  product 
will  be  contaminated  with  other  substances  which  then  make  their 
appearance.  The  ether  obtained  may  be  mixed  with  a  little  caustic 
potash,  and  redistilled  by  a  very  gentle  heat. 

"Pure  ether  is  a  colorless,  transparent,  fragrant  liquid,  very  thin 


GENERAL  ANESTHESIA.  433 

and  mobile.  Its  specific  gravity  at  60°  is  about  120 ;  it  boils  at  96° 
under  the  pressure  of  the  atmosphere,  and  bears,  without  freezing, 
the  severest  cold.  When  dropped  on  the  hand,  it  occasions  a  sharp 
sensation  of  cold,  from  its  rapid  volatilization.  Ether  is  very  com- 
bustible ;  it  burns  with  a  white  flame,  generating  water  and  carbonic 
acid.  Although  the  substance  is  among  the  lightest  of  liquids,  its 
vapor  is  very  heavy,  having  a  density  of  2.586.  Mixed  with  oxygen 
gas  and  fired  by  the  electric  spark,  or  otherwise,  it  explodes  with 
the  utmost  violence.  Preserved  in  an  imperfectly-stopped  vessel, 
ether  absorbs  oxygen  and  becomes  acid,  from  the  production  of 
acetic  acid.  This  attraction  for  oxygen  is  increased  by  elevation  of 
temperature."  {Fownes.) 

Dr.  Jackson's  formula  for  the  preparation  of  ether  for  anaesthetic 
purposes  is,  we  believe,  as  follows :  procuring  the  strongest  and 
purest  rectified  sulphuric  ether, — that  just  described, — wash  it  well, 
to  get  clear  of  any  acids  ;  then  decant  from  the  water,  drying  it 
with  chloride  of  calcium,  to  free  it  of  any  water  that  might  other- 
wise remain  from  the  washing. 

This,  however,  is  but  a  single  formula.  Different  chemists  arrive 
at  the  same  ends  through  different  processes.  The  surgeon  should 
buy  of  a  reliable  druggist  rather  than  attempt  the  preparation  for 
himself. 

This,  then,  is  ether,  an  agent  which,  as  experience  demonstrates, 
will  produce  insensibility  when  breathed  into  the  lungs.  To  exhibit 
ether  successfully,  four  essentials  seem  necessary: 

1st.  That  the  ether  should  be  very  pure. 

2d.  That  the  vehicle  upon  which,  or  with  which,  the  agent  is 
exhibited,  should  be  of  such  character  that  full  volume  of  atmo- 
spheric air  is  allowed  to  pass  through  the  ether  into  the  lungs. 

3d.  That  the  vapor  of  the  ether  be  properly  diluted,  given  for  the 
first  few  inspirations  comparatively  weak,  and  increased  in  strength 
as  the  glottis,  air-passages,  and  lungs  can  bear  it. 

4th.  That  insensibility  be  produced  as  quickly  as  the  system  will 
bear,  as  evinced  by  obvious  signs. 

A  cone-shaped,  close  sponge  is  the  best  means  for  administering 
ether.  This  possesses  every  advantage,  except  that  of  economy  in 
the  administration,  without  having  any  of  the  common  faults.  From 
two  to  five  minutes  will  be  found  the  average  time  necessary  to  pro- 
duce the  full  effect  of  perfect  sleep;  though  cases  will  present  them- 
selves where  double  this  time  will  be  required,  and  where,  indeed, 
it  may  be  necessary  to  combine  with  the  ether  the  more  powerful 

28 


434  ORAL  DISEASES  AND  SURGERY. 

effect  of  chloroform,  or  even  to  employ  the  undiluted  chloroform. 
From  an  article  emanating  from  a  gentleman  of  much  experience  in 
anaesthetic  agents,  we  take  the  following  suggestive  remarks: 

"It  is  possible  to  inspire  three,  four,  nay,  ten  times  the  quantity 
of  ether  capable  of  producing  sleep,  without  this  state  being  pro- 
duced, provided  the  vapor  be  taken  in  a  too  diluted  form  ;  and  we 
believe  this  over-dilution  and  its  consequent  protracted  inhalation  is 
a  frequent  cause  of  the  excitement  which  supervenes  in  the  practice 
of  many  persons,  while  it  so  rarely  shows  itself  in  that  of  others. 
In  these  cases  the  patient  may  be  made  drunk;  drunk  in  the  first 
degree,  but  not  dead  -  drunk,  the  condition  required  for  surgical 
purposes." 

It  will  be  remarked,  let  it  be  noticed  in  passing,  that  one  of  the 
most  common  objections  of  the  opponents  of  ether  lies  at  this  door, 
— this  supervening  state  of  excitement  instead  of  the  desired  state  of 
stupor;  but  does  not  the  question  again  very  pertinently  apply,  Is 
the  fault  with  the  agent,  or  with  the  operator? 

The  idea  is  to  be  conveyed  that  the  effects  of  sulphuric  ether  and 
of  the  common  alcoholic  beverages  are  the  same.  The  effects  of  alco- 
holic liquids  are  too  well  known  to  require  minute  description.  We 
have,  first,  the  state  of  exhilaration,  which  gradually  changes  to  com- 
plete stupefaction  or  narcotism  :  the  last  state,  the  result  probably 
of  a  narcotized  condition  of  the  brain.  Just  so  acts  ether,  yet  passing 
through  its  various  stages  more  quickly,  the  result  of  its  being 
poured  in  a  continuous  and  undiluted  stream  upon  the  heart  and 
brain.  The  ether  is  no  sooner  absorbed  than  the  blood  charged  with 
it  passes  to  the  left  side  of  the  heart,  and  immediately  thereafter  is 
cii'culated  through  the  coronary  vessels,  the  carotid  and  vertebral 
arteries,  and  thus  pervades  the  tissue  of  all  parts  of  the  heart,  as 
well  as  of  every  portion  of  the  brain.  A  writer,  in  an  influential 
dissertation,  presents  an  example  in  this  wise: 

"  Suppose,  to  take  an  extreme  illustration,  that  the  blood  M^as  as 
capable  of  absorbing  as  much  ether  as  water  can  combine  with,  or 
one-tenth  its  own  weight.  If,  then,  we  suppose  the  blood  in  the 
lungs  was  impregnated  to  this  extent,  it  would  be  applied  in  that 
state  to  the  heart  and  brain ;  whereas,  if  the  blood  in  the  stomachic 
vessels  was  impregnated  to  the  same  extent  with  ether,  before  reach- 
ing the  liver  it  would  have  mingled  with  more  than  its  own  mass 
of  pure  blood  from  the  splenic  and  mesenteric  veins.  The  tenth 
would  then  become  a  twentieth,  and,  on  the  blood  leaving  the  liver 
and  joining  the  larger  current  of  the  inferior  cava,  the  twentieth 


GENERAL  ANESTHESIA.  435 

would  become  a  fiftieth  or  sixtieth;  a  further  dilution  would  take 
place  at  the  confluence  with  the  superior  cava,  so  that  the  blood,  on 
reaching  the  heart  and  brain,  instead  of  containing  one-tenth  part  of 
absorbed  ether,  could  not  contain  as  much  as  one-hundredth.  When, 
therefore,  the  same  quantity  of  ether,  or  any  absorbable  substance, 
is  taken  up  from  the  lungs  and  from  the  stomach,  it  must,  in  the 
former  case,  be  applied  to  the  tissue  of  the  heart  and  brain  in  a  state 
of  concentration  at  least  ten  times  greater  than  the  latter,  and  will 
therefore  act  on  these  organs  with  more  suddenness  and  energy." 

The  evanescence  of  the  effect  of  ether,  as  compared  with  that  of 
alcohol,  is  explained  by  a  momentary  consideration  of  the  different 
manner  of  absorption.  During  the  inhalation  of  ether,  as  we  have  just 
seen,  the  charged  blood  is  applied  to  the  heart  and  brain,  while  the 
blood  circulating  in  the  lower  parts  of  the  body  contains  a  much 
smaller  proportion  of  it.  Now,  on  stopping  the  inhalation,  the  blood 
in  the  heart  and  brain  speedily  passes  off  by  the  veins,  and  is  suc- 
ceeded by  the  comparatively  pure  blood  coming  from  the  lower 
regions  of  the  body,  and  so  the  narcotic  symptoms  disappear. 

"It  is  far  otherwise  when  alcohol  is  absorbed  from  the  stomach, 
for  the  whole  mass  of  blood  must  be  impregnated  with  it  before  a 
highly-charged  blood  can  be  applied  to  the  heart  and  brain  ;  and 
then  the  effect  continues  for  many  hours,  till  the  alcohol  has  been 
thrown  out  of  the  system  by  the  lungs  and  skin.  With  respect  to 
ether,  it  must  not  be  supposed  that  on  the  subsidence  of  the  nar- 
cotism it  disappears  from  the  body ;  for  it  is  merely  weakened  in  its 
effects  by  being  diffused  over  the  whole  mass  of  blood.  This  is 
obvious,  from  the  smell  of  the  breath  for  many  hours,  and  from  its 
frequently  causing  copious  perspiration." 

Does  not  the  question  here  suggest  itself,  If  the  effects  of  ether 
and  of  the  common  alcoholic  beverages  are  so  nearly  alike,  why  the 
great  dread  of  the  one  and  the  entire  fearlessness  with  the  other  ? 
Would  not  the  answer  seem  to  be  something  of  this  kind?  Men 
when  etherized  are  as  dead-drunk :  our  eyes  are  accustomed  to 
seeing  them  only  partly  drunk.  In  this  state  they  excite  amuse- 
ment :  in  the  state  of  profound  drunkenness  they  have  always 
aroused  our  fears  for  their  recovery.  Associations  have  great 
weight. 

The  immediate  and  obvious  effects  of  etherization  on  the  individ- 
ual hardly  require  notice,  as  they  must  be  familiar  to  all  our  readers, 
if  not  from  a  personal  experience,  certainly  from  observation  upon 
others.     "  All  the  usual  phenomena  of  the  deepest  sleep  supervene, 


436  ORAL  DISEASES  AND   SURGERY. 

gliding  often  into  the  profoundness  of  sopor,  and  verging  occasion- 
ally upon,  if  not  actually  lapsing  into,  coma.  The  voluntary  mus- 
cles become  suddenly  relaxed,  the  jaw  falls,  the  arms  hang  down, 
the  eyes  roll  upward  under  the  lid,  the  respiration  becomes  slow  and 
labored,  and  the  face  becomes  either  very  pale  or  morbidly  flushed ; 
the  aspect  of  things  is  truly  such  as  can  hardly  be  contemplated  for 
the  first  time  without  alarm:  the  individual  seeming,  to  the  com- 
mon eye,  to  be  sinking  into  the  sleep  of  death." 

It  is  impossible,  says  another  observer,  to  see  a  single  case  of  ether- 
ization without  being  struck  with  its  resemblance  to  asphyxia  ;  and 
experiments  exhibit  a  real  relation  between  the  two.  But  in  ordinary 
asphyxia  the  nervous  system  loses  its  power  under  the  influence  of 
black  blood,  or  blood  deprived  of  its  oxygen.  But  in  etherization  it 
does  so  under  the  direction  of  this  singular  agent.  This  is  really 
all  the  difference,  for  in  both  there  is  the  same  loss  of  sensation  and 
voluntary  motion,  and  the  same  at  least  temporary  persistence  of 
the  respiratory  movements.  In  one  word,  there  is  the  same  survival 
of  the  medulla  oblongata  over  the  spinalis. 

"  Etherization  exhibits  to  us  the  entire  mechanism  of  asphyxia :  we 
mean  the  successive  deaths  of  the  various  nervous  centres.  It  iso- 
lates, just  as  mechanical  experiments  do,  the  intellectual  powers, 
the  co-ordination  of  the  movements,  sensibility,  motility,  life.  The 
isolation  of  life — this  point,  this  vital  knot  of  the  nervous  system — 
forms  the  most  striking  point  of  the  experiments. 

"  In  an  etherized  animal  one  point  alone  survives,  and  while  it  does 
so,  all  others  retain  at  least  a  latent  life,  and  may  resume  their  active 
life;  this  point  once  dying,  all  dies." 

Throwing  out  of  immediate  consideration  the  idiosyncrasies,  let 
us  for  a  few  moments  consider  the  question  of  the  general  safe  ex- 
hibition of  the  agent. 

The  safest  agent  may  be  made  a  source  of  ill  :  as  the  intruder  on 
the  physical  laws  of  his  organism  must  sutler  the  consequences  of 
his  ignorance  or  temerity,  so  may  any  agent,  however  good,  be  made 
an  injury  by  its  abuse.  As  the  imbibition  of  alcoholic  beverages  may 
be  carried  to  a  point  beyond  which  the  life-principle  reacts  not,  just 
so,  and  as  the  warmest  supporters  of  the  anaesthetics  would  have 
impressed,  may  ether  be  made  an  instrument  of  irreparable  injury, 
blasting  and  destroying  where  it  was  designed  to  refresh  and  save. 

To  lay  down  certain  reliable  rules,  applicable  in  all  cases,  for  the 
process  of  etherization,  is  an  impossibility.  The  presentments  of 
conditions  in  various  individuals  ditfer  so  materially,  that  it  would 


I 


GENERAL  ANESTHESIA.  437 

be  charlatanism  to  act  upon  any  but  rules  resulting  in  a  general 
knowledge  of  the  agent  and  a  comprehension  of  physiological  laws 
and  pathological  alternations.  One  person,  as  Dr.  Snow  remarks, 
"  shall  become  impassable  as  the  subject  on  the  dissecting-table ; 
another  talks  incoherently  or  mirthfully,  replies  to  questions,  or 
obeys  directions;  others  utter  exclamations  of  pain,  which  they 
afterward  retain  no  reminiscence  of  having  felt ;  and  others  again 
declare  that  they  have  suifered  pain  but  felt  themse:lves  powerless 
for  its  expression.  Finally,  in  not  a  few,  ungovernable  violent  or 
convulsive  action  takes  place,  quite  adverse  to  the  performance  of 
any  delicate  surgical  operation.  With  some  an  utter  oblivion  is 
induced  ;  while  others,  while  undergoing  all  the  apparent  torture  of 
a  prolonged  dissection,  are  reveling  in  the  realms  of  memory  and  in 
the  fields  of  imagination."  M.  Jobart  and  other  observers  have 
attempted  to  lay  down  three  distinct  stages  in  the  effects  of  the  agent, 
according  to  the  prolongation  of  the  etherization.  1.  That  of  inco- 
herence, agitation,  or  delirium,  as  the  case  may  be.  2.  Acceleration 
of  the  pulse,  with  loss  of  sensibility  and  loss  of  power.  3.  Exhaustion 
and  coldness  of  the  surface.  As  we  have  remarked,  the  matter  cannot 
thus  be  methodically  laid  down,  for  it  is  quite  certain  that  any  of 
these  conditions  may  be  induced,  in  diflPerent  individuals,  by  very 
various  doses  of  ether;  while  others,  again,  are  susceptible  of  only 
the  first  degrees,  to  appearances,  and  yet  enjoy  an  immunity  from 
suffering  during  operations.  Even  the  quickened  condition  of  the 
pulse  and  respiration,  and  that  almost  universally  employed  crite- 
rion, the  stationary  condition  of  the  pupil,  may  deceive  in  the 
supposed  impression  produced. 

A  number  of  the  French  Academicians  some  years  back  instituted 
a  series  of  experiments  upon  animals,  for  the  purpose  of  determining 
the  mode  and  order  in  which  the  various  portions  of  the  cerebro- 
spinal system  were  influenced  during  inhalation.  The  following  are 
some  of  the  conclusions  arrived  at  by  the  veteran  vivisectdr.  Baron 
Flourens : 

"  The  action  of  ether  upon  the  nervous  centres  follows  in  a  given 
course.  It  acts,  first,  upon  the  cerebral  lobes,  disturbing  the  intellect. 
It  acts,  secondly,  upon  the  cerebellum,  deranging  the  equilibrium  of 
the  movements  of  the  animal.  Thirdly,  it  acts  upon  the  medulla 
spinalis,  in  which  it  extinguishes,  successively,  the  sensory  and 
motor  principles;  and,  lastly,  it  acts  upon  the  medulla  oblongata, 
where  arrived,  life  becomes  extiact." 

To  produce  the  best  effects  of  sulphuric  ether,  it  is  of  the  first 


438  ORAL   DISEASES  AND   SURGERY. 

consequence  that  an  entirely  reliable  article  be  employed.  "  For 
myself,"  says  Dr.  Robinson,  of  London,  "I  feel  convinced  that  many 
of  the  failures  that  have  occurred  in  its  administration  in  some 
measure  may  be  attributed  to  the  imperfect  preparation  of  the  fluid. 
I  have  myself  obtained  ether  of  various  specific  qualities  from  dif- 
ferent chemists;  and  on  one  occasion,  requiring  an  extra  quality  for 
a  series  of  experiments,  the  gentleman  supplying,  being  out  of  that 
quality  he  had  generally  furnished,  sent  some  of  a  different  kind 
which  he  had  in  his  establishment,  w^hich  was  administered  in 
two  cases.  I  found,  however,  I  could  only  produce  partial  uncon- 
sciousness, not  insensibility  to  pain,  and  therefore  deferred  the 
operations,  which  were  upon  the  teeth.  I  afterward  procured  some 
of  the  first  quality  ether,  and  employed  it  in  the  same  case  with 
success." 

The  effect  of  a  bad  article  of  ether  is  not  only  the  inability  on  the 
part  of  the  operator  to  produce  more  than  a  partial  unconsciousness, 
but  it  is  almost  certain  to  produce  nausea,  giddiness,  and  prostra- 
tion.    If  a  good  article  cannot  be  procured,  better  use  none  at  all. 

The  quantity  of  ether  that  may  be  given  to  any  individual  patient 
is  a  matter  for  the  practitioner  to  decide  upon  in  connection  with 
each  case.  It  is  impossible  to  fix  the  dose  of  vapor  that  will  be 
required  to  produce  given  effects  upon  any  patient,  neither  is  it 
always  an  easy  matter  to  decide  when  just  enough  has  been  admin- 
istered. We  cannot  rely  implicitly  on  the  state  of  the  pupil  or  pulse, 
or  upon  what  is  considered  by  so  many  as  an  exact  indication, — 
namely,  the  insusceptibility  of  the  eyelids  to  impressions  made  by 
striking  the  hairs.  Perhaps  the  changes  in  the  breathing  are  the 
most  reliable  signs:  these  certainly  influence  me  most;  so  long  as 
breathing  continues  easy  and  natural,  little  danger  is  to  be  antici- 
pated, but  the  moment  it  becomes  labored,  one  is  to  proceed  or 
recede  cautiously.  In  etherizing  a  patient,  let  the  operator  watch 
the  pulse,  the  expression,  and  the  respiration.  So  long  as  these 
give  no  counter-indications,  the  exhibition  may  be  carried  forward 
to  the  end  desired. 

As  to  the  question  of  the  continuance  of  a  patient  in  the  anaesthetic 
condition,  I  think  it  will  be  found  the  proper  rule  to  make  the  time 
just  as  short  as  possible  :  that  is  to  say,  as  the  continuance  of  the 
exhibition  of  the  agent  is  concerned.  If  an  operation  to  be  per- 
formed in  the  anaesthetic  condition  may  be  completed  in  five,  ten,  or 
fifteen  minutes,  it  is  not  good  policy  to  prolong  it,  and  with  it  the 
continued  administration  of  the  ether,  to  a  half  or  a  full  hour.     That 


GENERAL  ANESTHESIA.  439 

there  is,  however,  any  imperative  or  absolute  necessity  to  hurry 
through  an  ether  case  is  not  at  all  implied.  I  have  known  a  patient 
kept  continuously  under  ether  for  forty-two  hours  ;  and  in  obstet- 
rical practice  ten  or  twelve  hours  of  anaesthesia  is  not  at  all  unfre- 
quent.  I  only  contend  that  it  is  neither  necessary  nor  prudent  to 
prolong,  without  object,  the  condition.  Where,  however,  such  a 
prolonged  action  is  demanded,  it  is  to  be  secured,  not  by  keeping  the 
saturated  sponge  constantly  applied  over  the  air-passages,  but  by 
applying  it  at  such  intervening  periods  as  may  be  necessary  to  pre- 
serve the  anaesthesia. 

The  condition  of  the  temperature,  as  might  be  inferred,  has  much 
to  do  with  prolonging  or  shortening  the  time  commonly  considered 
necessary  to  place  a  patient  in  a  state  of  sleep.  Dr.  Snow  obtained, 
from  experiments,  the  following  results : 

One  hundred  cubic  inches  of  air,  saturated  with  the  vapor  of 
ether,  at  a  temperature  of 

44°  would  contain  27    cubic  inches  of  vapor. 
54°  "  24.3 

64°  "  43.3 

Y4°  "  53.6 

84°  "  66.6 

Being  doubled  by  a  rise  of  only  thirty  degrees ;  or,  in  other  words, 
if  at  a  temperature  of  84°  Fahrenheit  we  employ  two  or  two  and 
a  half  minutes  in  affecting  a  person  to  the  state  desired,  at  a  tem- 
perature thirty  degrees  lower  we  would  require  from  four  and  a  half 
to  six  minutes  to  obtain  the  same  result. 

Concerning  the  idiosyncrasies,  I  would  speak  my  own  experience 
by  saying  that  I  have  never  yet  met  with  a  person  who  I  thought 
might  not  take  ether,  or  ether  in  combination  with  chloroform.  The 
London  Medical  Gazette  considers  its  use  inadmissible  where  there 
is  a  tendency  to  apoplexy  or  epilepsy,  and  also  in  plethoric  individuals. 
Another  intelligent  source  says  that  persons  presenting  the  slightest 
signs  of  being  cataleptic  should  be  viewed  as  idiocratical.  Persons 
under  the  influence  of  liquor,  it  is  generally  considered,  should  be 
viewed  for  the  time  as  not  fit  subjects. 

In  a  conversation  with  Dr.  J.  B.  F.  Flagg,  had  several  years  back, 
that  experienced  man  told  me  that  he  believed  in  no  idiosyncra- 
sies, except  it  might  be  a  very  high,  nervous  temperament;  that 
he  had  administered  ether  to  the  infant  of  thirty-six  hours  and  to 
persons  in  extreme  old  age ;  had  given  it  to  the  robust  and  the 
weak,  the  plethoric  and  the  consumptive;  had  used  it  in  all  stages 


440  ORAL  DISEASES   AND   SURGERY. 

of  pregnancy,  except  that  stage  known  as  quickening :  would  also 
exhibit  it  here,  but  would  feel  called  on  to  exercise  more  than  ordi- 
nary care.  Seeming  idiosyncrasies  might  generally,  he  thought, 
be  explained  by  an  examination  of  the  operator's  ignorance  of  the 
agent.  The  faith  of  this  gentleman  in  the  perfect  safety  of  the  use 
of  ether  was  so  great  that  he  remarked  he  would  not  hesitate  to  use  it 
where  there  had  been,  or  was,  aneurism  of  the  aorta.  The  opinion 
of  Dr.  Flagg  concerning  the  non-existence  of  idiosyncrasies  is  to  be 
taken  before  that  of  most  persons,  either  of  this  country  or  Europe. 
His  opportunities  for  observation  were  not  surpassed  by  those  of 
any  other  person,  and  perhaps  equaled  by  few.  A  work  published 
by  him  in  1854,  long  before  his  retirement  from  practice,  has  not, 
up  to  the  present  day,  been  advanced  on,  and  is  an  heirloom  to  be 
valued  by  those  to  whom  his  industry  has  left  it. 


CHAPTER     XIX. 


GENERAL   ANESTHESIA. 


From  the  consideration  of  sulphuric  ether  we  may  pass  to  an 
investigation  of  the  character  and  merits  of  the  perchloride  of 
formyle,  or  chloroform.  This  agent  is,  without  doubt,  the  most 
powerful  and  reliable  of  the  anaesthetics;  but,  unfortunately,  it  pos- 
sesses qualities  which  render  it  not  unfrequently  fatal  to  life,  and 
therefore  make  it  of  less  value  than  the  one  we  have  just  been  con- 
sidering. No  person  should  employ  chloroform  who  is  not  prepared 
to  meet  many  emergencies. 

To  procure  chloroform,  the  chemist  takes  of  chlorinated  lime  say 
(to  take  a  common  formula),  lb.  iv;  rectified  spirits,  Oss;  water,  Ox; 
chloride  of  calcium,  broken  in  pieces,  5j-  Put  the  lime,  first  mixed 
with  water,  into  a  retort,  and  add  the  spirits,  so  that  the  mixture 
may  fill  only  the  third  part  of  the  retort.  Then  heat  them  in  a  sand- 
bath,  and  as  soon  as  ebullition  begins  withdraw  the  heat  as  quickly 
as  possible,  lest  the  retort  should  be  broken  by  the  sudden  increase 
of  heat.  Let  the  liquor  distill  into  the  receiver  so  long  as  there  is 
nothing  which  subsides,  the  heat  being  reapplied  if  necessary.  To 
the  distilled  liquid  add  a  quarter  of  the  water,  and  shake  them  all 
well  together.  Carefully  separate  the  heavier  portion,  which  sub- 
sides, and  add  the  chloride  to  it,  and  frequently  shake  them  for  an 
hour.  Lastly,  let  the  liquid  distill  again  from  a  glass  retort  into  a 
glass  receiver. 

In  appearance,  chloroform  resembles  the  freshest  water  of  the 
mountain-spring.  To  the  taste  it  is  hot  and  very  sweet;  to  the 
nostril  it  has  much  the  odor  of  the  common  strawberry.  When 
dropped  upon  linen  it  evaporates  very  quickly,  leaving,  if  pure,  no 
stain  or  sign  behind.  In  weight  it  is  quite  one-half  heavier  than 
water,  and,  as  its  vapor  is  concerned,  is  four  times  heavier  than 
atmospheric  air. 

The  smell  of  chloroform,  says  Dr.  Snow,  should  be  esteemed  one 
of  the  best  tests  of  its  purity  and  identity.     When  dropped  on  the 

(441) 


442  ORAL  DISEASES  AND  SURGERY. 

hand  it  should  quickly  evaporate,  leaving  not  the  least  smell  or 
moisture  behind.  If  a  disagreeable  odor  remains  on  the  hand  after 
the  evaporation,  the  chloroform  has  probably  been  made  from  impure 
spirits,  or  even  from  wood  or  acetone,  and  is  therefore  unfit  for  me- 
dicinal purposes.  When  chloroform  becomes  decomposed  from  any 
cause,  it  acquires  a  greenish-yellow  color,  and  gives  off  chlorine  and 
h^^drochloric  acid,  so  that  the  alteration  is  at  once  apparent.  When 
chloroform  is  pure,  it  has  no  reaction  on  test-paper,  but  is  quite 
neutral.  The  best  way,  according  to  Dr.  Snow,  to  detect  a  small 
quantity  of  hydrochloric  acid  in  it,  is  to  moisten  a  slip  of  blue  litmus 
paper  with  distilled  water,  and  hold  it  just  within  the  neck  of  the 
bottle  exposed  to  the  vapor.  If  sulphuric  acid  be  present,  it  may 
be  discovered  by  agitating  the  chloroform  with  distilled  water  and 
adding  nitrate  of  baryta. 

Chloroform  may  be  degraded  by  admixture  with  alcohol,  and  this 
can  be  done  without  making  any  perceptible  change  in  its  appear- 
ance :  its  specific  gravity,  however,  is  thereby  lowered  ;  and,  accord- 
ing to  M.  Mialbe,  the  foreign  presence  is  most  easily  detected  by 
adding  to  the  suspected  fluid  a  small  quantity  of  water,  when  a 
milky  opacity  results. 

Chloroform,  as  the  heart's  action  is  concerned,  is  a  powerful  seda- 
tive. In  nearly  if  not  quite  all  the  fatal  cases  resulting  from  the 
administration  of  this  agent,  cardiac  syncope  has  been  the  cause  of 
death  ;  and  in  a  very  small  minority  of  the  cases  indeed  has  there 
been  any  evident  interference  with  the  process  of  respiration.  This 
fact  is  always  to  be  held  in  strictest  remembrance  when  exhibiting 
the  agent. 

In  oral  surgery,  where  it  is  desirable  to  produce  the  profoundest 
and  most  prolonged  primary  impression,  chloroform,  if  it  were 
without  danger,  is  the  anaesthetic  most  indicated  and  required.  In- 
deed, in  my  own  practice  I  find  many  cases  where  I  do  not  seem 
to  be  able  to  get  along  without  it,  using  it  either  alone  or  in  associa- 
tion with  the  ether.  Therefore,  because  its  use  is  so  frequently 
necessary,  the  oral  surgeon  should  make  himself  as  familiar  as  pos- 
sible with  all  that  concerns  its  defects  as  well  as  its  virtues. 

Experiments  have  demonstrated  that  eighteen  minims  of  chloro- 
form is  the  average  quantity  necessary  to  put  an  adult  in  a  con- 
dition of  insensibility  to  surgical  operations, — that  is  to  say,  that 
this  amount  should  be  absorbed  and  carried  to  the  nerve-centres. 

It  has  also  been  shown  "  that  chloroform  vapor  has  the  effect  of 
suddenly  arresting  the  action  of  the  heart,  when  it  is  mixed  with 


GENERAL  ANAESTHESIA.  443 

the  respired  air  to  the  extent  of  eight  or  ten  per  cent,  or  upward." 
With  these  two  lessons  appreciated,  it  is  seen  that  the  manner  and 
character  of  the  exhibition  of  the  agent  have  much  to  do  with 
the  result.  Not  everything,  however,  as  it  is  undeniable  that  fatal 
accidents  have  occurred  in  the  best  and  most  skillful  hands,  although 
in  these  latter  cases  the  inference  is  to  be  drawn  that  the  deaths 
occurred  from  idiosyncrasies. 

Eighteen  minims,  according  to  Dr.  Snow,  are  to  be  absorbed  from 
thirty-six  breathed  ;  allowing  thus  that  one-half  is  lost  in  expiration. 
But  temperature,  as  in  the  case  of  the  ether,  has  much  to  do  with 
the  taking  up  of  such  a  quantity.  The  following  table  comprises 
the  experiments  of  Dr.  Snow  in  this  direction.  At  a  temperature 
of  40°  Fahrenheit,  one  hundred  cubic  inches  of  air  will  take  up  but 
seven  cubic  inches  of  the  vapor. 

At  45°  8  cubic  inches.  At  70°  24  cubic  inches. 

50°  9           "  t5°  29 

55°  11           "  80°  36 

60°  14           "  85°  44 

65°  19           "  90°  55 

This  table  readily  exhibits  the  fact  that  anaesthesia  by  the  use  of 
chloroform  must  come  on  at  varying  periods,  and  that  therefore  no 
judgment  of  its  proper  exhibition  is  to  be  derived  in  this  direction. 
Again,  outside  of  these  atmospheric  associations,  the  manner  of 
the  exhibition  would  have  much  to  do  with  the  minims  inspired : 
where,  for  example,  it  is  exhibited  poured  over  a  single  layer  of 
linen  (as  upon  a  handkerchief  laid  over  the  face),  quite  as  much 
would  be  lost  in  the  surrounding  atmosphere  as  would  be  inhaled 
into  the  lungs. 

Considering  the  danger  as  arising  from  the  direction  of  cardiac 
syncope,  advantage  is  to  be  taken  of  all  conditions  antagonistic  to 
such  depression.  In  bloodletting,  it  is  known  that  such  a  condition 
is  much  the  most  readily  brought  about  when  the  operation  is  per- 
formed on  the  patient  standing,  and  when  the  primary  impression 
is  made  most  marked  through  a  large  exit  for  the  blood.  In  states 
of  depression,  arising  from  whatever  cause,  either  of  physical  or 
mental  disturbance,  such  tendency  is  increased.  A  surgeon  always 
hesitates  to  bleed  a  depressed  patient;  or,  if  such  bleeding  seems  a 
necessity,  supporting  means  are  employed  and  continued  in  con- 
junction with  the  bloodletting.  Advantage  is  taken  also  of  all  col- 
lateral indications,  as,  for  example,  position,  the  patient  lying  down, 


444  ORAL  DISEASES  AND   SURGERY. 

the  head  perhaps  being  placed  on  a  lower  plane  than  the  body,  the 
orifice  of  exit  being  made  very  small,  intermissions  in  the  flow  of 
the  blood,  stimulants,  as  the  pre-exhibition  of  brandy  or  wine,  kind 
and  encouraging  assurances,  etc.  The  depressing  effect  of  fear  on 
the  heart's  action  is  never  to  be  lost  sight  of  in  the  administration 
of  chloroform.  How  many  patients  faint  even  while  preliminary 
arrangements  in  anticipation  of  an  operation  are  going  forward  I 
and,  indeed,  how  many  are  the  cases  on  record  of  death  from  such 
fright!  It  would  seem,  then,  that  one  would  never  be  justified  in 
administering  chloroform  to  a  patient  laboring  under  any  marked 
depression  ;  at  least  such  is  my  own  conviction,  and  upon  such  con- 
viction I  have  always  acted.  All  persons,  or  nearly  all,  approach 
an  operation  with  a  certain  amount  of  trepidation ;  but  such  fear  may, 
in  the  majority  of  cases,  be  dispelled ;  or  if  this  is  impossible,  then 
a  preliminary  artificial  courage  may  be  given  by  the  use  of  brandy, 
or  cerebral  consciousness  may  be  disturbed  by  the  inhalation  of  a 
few  drachms  of  ether. 

The  objection  that  chloroform  should  not  be  administered  to  a 
patient  in  a  sitting  position  does  not,  however,  seem  to  hold  entirely 
good.  In  oral  surgery  this  is  nearly  always  the  necessar}'^  position  ; 
and  I  have  thus  administered  it,  in  perhaps  hundreds  of  cases,  with- 
out ever  having  had  any  ill  result.  A  difference  in  the  character 
of  cardiac  syncope  is  here  to  be  recognized.  The  paralysis  may 
arise  from  two  sources,  and  exhibit,  as  the  state  of  the  heart  is  con- 
cerned, quite  different  appearances;  that  is,  there  is  a  syncope  of 
anaemia  and  a  syncope  of  narcotism.  Now,  while  there  is  between 
these  two  conditions  much  relationship,  as  the  que.stion  of  a  vital 
propulsive  force  is  concerned,  yet  there  are  also  certain  differences, 
of  which,  as  surgeons,  we  may  take  advantage.  Paralysis  of  the 
heart  occurs  when,  from  any  reason,  the  organ  is  deprived  of  the 
effect  of  its  natural  stimulus,  the  blood:  this  is  the  syncope  or  paral- 
ysis of  anaemia.  It  occurs  again  when,  through  the  action  of  a 
common  or  specific  narcotic,  its  muscular  fibres  are  relaxed  and 
deadened.  The  two  causes  may  exist  and  act  in  conjunction. 
Chloroform  is  a  specific  narcotic,  as  the  heart  is  concerned ;  at  least 
this  would  seem  to  be  the  deduction  from  post-mortems  made  in  the 
fatal  cases  of  its  exhibition.  In  anaemia,  syncope  is  partly  a  me- 
chanical production  ;  the  patient,  in  a  standing  position,  faints,  as 
the  result  of  gravity  countei'balancing  the  natural  distribution  of 
the  blood.  In  narcotic  syncope,  position  is,  perhaps,  of  little  con- 
sequence, at  least  as  the  action  of  the  producing  cause  is,  of  itself. 


GENERAL  ANESTHESIA.  445 

concerned.  The  question,  then,  of  sitting  or  lying,  as  the  exhi- 
bition is  concerned,  resolves  itself  into  a  consideration  of  the  state 
of  the  general  health  of  a  patient :  if  there  is  deficiency  either  in 
quality  or  amount  of  the  vital  fluid,  then  the  erect  or  even  serai- 
erect  position  should  never  obtain.  If,  on  the  contrary,  a  patient 
does  not  present  such  conditions,  then  it  would  seem  there  is  no 
special  danger  in  such  position. 

Prefatory  stimulation,  if  not  contra-indicated,  is  happily  employed 
in  conjunction  with  chloroform.  A  tablespoonful  or  more  of  brandy 
given  to  a  patient  some  five  or  ten  minutes  before  the  exhibition  of 
chloroform,  will  frequently  support  the  natural  action  of  the  heart 
through  a  prolonged  operation,  and  thus  dismiss  the  common  source 
of  alarm. 

In  my  own  practice  I  never  like  to  use  chloroform  but  in  conjunc- 
tion with  ether  ;  not  mixing  them,  as  in  the  common  chloric  ether,  but 
alternating,  as  the  case  seems  to  require  or  allow.  Thus,  employing 
the  cone  of  sponge,  I  commence  the  process  by  pouring  within  it  a 
quantity  of  ether,  when  it  is  gradually,  and  yet  as  rapidly  as  possible, 
brought  to  cover  the  mouth  and  nostrils.  If  now  I  find  the  pulse 
rapidly  increasing,  or  even  remaining  fixed  and  steady,  and  par- 
ticularly if  undue  cerebral  excitability  manifests  itself,  I  drop  into 
the  cone  ten  or  twenty  drops  of  chloroform.  This  will  generally  be 
found  to  quiet  the  patient  almost  instantly.  From  this  point  I  pro- 
ceed, using  principally  the  chloroform  or  ether,  according  to  the 
result  to  be  secured.  If  an  operation  is  one  of  simple  character  and 
of  quick  performance,  as  the  extraction  of  teeth,  or  the  making  of 
some  simple  puncture  or  incision,  then  I  think  we  had  better  not 
risk  anything  with  chloroform.  If,  on  the  contrary,  it  is  some  difiS- 
cult  and  tedious  case  about  the  mouth,  where,  after  commencing,  the 
surgeon  cannot  well  stop  to  readminister  the  anaesthetic,  then  I  take 
the  risk  of  the  excess  of  chloroform  for  the  prolonged  effect  it  yields 
and  the  greater  profundity  of  the  impression  it  secures. 

The  manner  of  the  exhibition  of  the  agent  would  have,  as  one 
would  infer,  much  influence,  as  the  result  is  concerned.  Thus,  of 
the  various  apparatuses  that  have  from  time  to  time  been  devised  to 
assist  in  the  use  of  chloroform,  many  are  deserving  of  no  better 
name  than  life-traps;  and  in  this  connection  one  naturally  finds 
himself  wondering  at  the  character  of  contrivances  which,  particu- 
larly in  the  earlier  history  of  chloroform,  were  employed,  even  by 
the  ablest  men,  in  experiments  directed  to  the  testing  of  the  general 
safety  and  results  of  the  agent.    I  can  never  read  of  the  white  mice. 


446  ORAL  DISEASES  AND   SURGERY. 

and  guinea-pigs,  and  cats,  and  bell-jars  of  these  pioneers,  without 
wondering  that  it  should  never  have  occurred  to  the  experimenters 
that  animals  might  as  readily  die  from  lack  of  proper  respirable  air 
as  from  the  effects  of  chloroform. 

In  using  pure  chloroform,  it  is  most  desirable  that  there  should 
be  the  fullest  admixture  with  air;  with  this  intention  we  use  the 
sponge,  first  softening  it  with  warm  water,  which  water  is  to  be 
well  squeezed  away.  The  respiration  should  be  easy  and  natural, 
and  the  patient  fully  e7i  rappoi't  with  the  operator.  He  should  be 
given  to  understand  that  anaesthesia  is  but  a  gentle  and  harmless 
sleep,  and  that  one  should  enter  upon  such  a  condition  as  he  enters 
upon  natural  slumber.  If  such  confidence  can  be  secured,  there  will 
not  be  found  much  trouble  in  producing  narcotism.  Another  plan 
of  using  the  agent,  and  one  which  has  many  advocates,  is  to  let  fall 
drop  after  drop  upon  a  napkin,  laid  loosely  over  the  air-passages. 

However  employed,  the  principal  indication  is  to  have  the  agent  in 
proper  dilution  and  combination  with  atmospheric  air:  this  secured, 
any  mode  of  inhalation  must  be  a  proper  one.  Insensibility,  as  re- 
marked by  Dr.  Snow,  is  not  caused  so  much  by  giving  a  dose  as  by 
performing  a  process.  Nature,  continues  this  gentleman,  supplies 
but  one  mixture  of  diluted  oxygen,  from  which  each  creature  draws 
as  much  as  it  requires;  and  so,  in  causing  narcotism  by  inhalation, 
if  a  proper  mixture  of  vapor  and  air  is  supplied,  each  patient  will 
gradually  inhale  the  requisite  quantity  of  the  former  to  cause  in- 
sensibility, according  to  his  size  and  strength.  It  is  desirable  to 
vary  the  proportions  of  vapor  and  air,  but  rather  according  to  the 
purpose  one  has  in  view,  whether  medicinal,  obstetric,  or  surgical, 
than  on  account  of  the  age  or  strength  of  the  patient;  for  the  respira- 
tory process  bears  such  a  relation  to  the  latter  circumstances  as  to 
cause  each  person  to  draw  his  own  proper  dose  from  a  similar  at- 
mosphere in  a  suitable  time. 

The  induction  of  insensibility  varies  with  the  individual,  or 
rather,  I  may  say,  with  classes  of  individuals.  One  class  will  breathe 
quietly  and  slowly,  until  unconsciousness  supervenes  as  if  by  a 
natural  sleep :  persons  of  this  class  are  of  the  lymphatic  temperament. 
The  nervo-sanguine  or  bilious  class  are  apt  to  become  restive  and 
frightened,  and  require  a  great  amount  of  care  and  attention,  being 
the  most  difficult  to  impress.  The  true  and  full  nervous  class,  while 
timid  and  frightened,  are  apt  to  be  impressed  by  a  very  few  inhala- 
tions. There  is  one  question  that  here  arises  in  regard  to  the  exhi- 
bition of  timidity.     When  a  patient  becomes  restive  and  excited, 


GENERAL  ANESTHESIA.  447 

shall  the  chloroformization  go  on  ?  Yes,  I  would  answer,  if  such 
exhibition  is  associated  with  mental  disturbance  produced  by  the 
chloroform  ;  for  here  it  is  not  as  the  condition  previously  named,  but 
is  rather  an  hallucination.  These  patients  should  be  forced  rapidly 
beyond  such  states  of  excitement ;  and  here  is  the  point  in  which  the 
production  of  anaesthesia  demands  the  greatest  skill,  courage,  and 
judgment.  I  have  over  and  over  seen  incompetent  operators  worry 
a  poor  creature  into  a  most  wretched  condition  simply  by  fearing  to 
pass  this  Rubicon  of  excitement.  If  assured  that  all  is  right  (and 
such  assurance  is  to  be  derived  from  the  general  aspect  of  the 
patient  rather  than  from  any  special  signs),  we  are  to  get  over  this 
intermediate  excitable  stage  as  quickly  as  possible,  and  get  over  it  by 
concentrating  the  chloroform.  Patients  laboring  under  this  excita- 
bility will,  often  enough,  assure  you  that  they  feel  that  another  inha- 
lation will  kill  them  ;  that  it  is  impossible  to  breathe;  that  the  heart 
is  laboring  under  a  wonderful  depression;  with  many  complaints  of 
like  character.  Such  speeches  are  mostly  to  be  taken  cum  grano 
salts :  the  practitioner  must  judge  for  himself. 

Before  an  operation  of  any  magnitude  is  commenced,  it  behooves 
the  surgeon  to  assure  himself  that  his  patient  is  in  the  proper  anaes- 
thetic condition.  Entire  paralysis  of  the  muscles  of  animal  life  is 
commonly  received  as  indicative  of  such  a  state, — this  being  mani- 
fested in  the  lifeless  falling  of  an  arm  when  raised.  But  this  is  not 
strictly  reliable,  as  to  obtund  sensation  we  are  aware  the  posterior 
root  of  the  spinal  cord  is  to  be  affected,  while  loss  of  motion  implies 
only  anaesthesia  of  the  anterior  root.  So  quickly,  however,  does  the 
action  of  the  agent  pass  from  the  one  to  the  other,  that  this  sign 
is  found  to  be  one  most  convenient  of  acceptance.  Dr.  Snow,  so 
far  as  I  am  aware,  was  the  first  to  call  attention  to  indications 
afforded  by  the  eyelashes:  this  test  I  have  depended  on  for  years,  and 
usually  find  it  reliable.  Just  after  unconsciousuess  is  induced,  remarks 
this  observer,  the  eyelashes  are  often  closed  very  strongly  when  their 
margins  are  touched,  especially  in  females,  and  there  seems  to  be  a 
positive  hypertesthesia ;  this,  however,  is  only  apparent,  and  arises 
from  the  control  of  the  will  being  removed  while  sensibility  remains. 
By  continuing  the  chloroform  the  sensibility  of  the  edges  of  the  eye- 
lids diminishes,  until,  at  last,  the}''  may  be  touched  without  causing 
winking.  Under  these  circumstances,  the  most  severe  operation  may, 
in  almost  every  case,  be  commenced  without  pain.  Upon  this  indica- 
tion of  the  eyelids,  Dr.  Snow  thinks  we  may  so  entirely  depend,  as 
ordinary  cases  are  concerned,  as  to  accept  from  them  information  as 


448  ORAL  DISEASES  AND  SURGERY. 

to  the  exact  extent  of  anassthesia  existing.  When,  for  instance,  he 
says,  touching  the  margins  of  the  lids  causes  very  slight  and  lan- 
guid winking,  the  patient  will  commonly  flinch  a  little  if  the  knife  is 
used,  but  only  in  a  manner  that  can  be  easily  restrained  and  that 
will  not  interfere  with  the  majority  of  operations. 

Three  degrees  of  narcotism  are  described.  "  The  first  degree  in- 
cludes all  the  effects  of  chloroform  that  exist  while  a  patient  retains 
a  perfect  consciousness  of  where  he  is  and  what  is  occurring.  In 
the  second  degree  there  is  no  longer  correct  consciousness.  The 
mental  functions  are  impaired,  but  not  necessarily  suspended.  In 
the  third  degree  there  are  no  longer  any  voluntary  motions." 

The  circumstances  which  influence  or  modify  the  effects  of  chloro- 
form are  thus  considered  by  Dr.  Snow,  than  whom,  perhaps,  there 
is  no  one  whose  observations  have  been  of  a  more  extended  or 
thorough  nature;  although  it  is  not  to  be  overlooked  that  he  was  so 
enthusiastic  in  this  direction  that  perhaps,  in  some  instances  at  least, 
his  prejudices  may  have  influenced  somewhat  his  judgment. 

"  I  arrived  at  the  conclusion,"  says  he,  "  after  much  careful  obser- 
vation, that  chloroform  might  be  given  with  safety  and  advantage 
in  every  case  in  which  the  patient  requires,  and  is  in  a  condition  to 
undergo,  a  surgical  operation.  And  having  acted  on  this  conclusion 
for  several  years,  I  have  found  no  reason  to  change  it.  It  is  de- 
sirable, however,  to  pay  attention  to  every  circumstance  connected 
with  the  health  and  constitution  of  the  patient  before  exhibiting 
chloroform,  as  many  of  these  circumstances  influence  its  effects." 

Age. — "  The  age  of  a  patient  has  considerable  influence  in  modi- 
fying the  effects  of  chloroform.  It  acts  very  favorably  on  children. 
They  sometimes  oppose  the  inhalation  of  it  as  long  as  they  are  con- 
scious, but  it  does  not  occasion  the  rigidity  and  struggling,  after  loss 
of  unconsciousness,  which  are  sometimes  met  with  in  the  adult. 
Anaesthesia  is  generally  induced  with  a  less  amount  of  narcotism  of 
the  nervous  centres  in  children  than  in  grown  persons. 

"  The  effects  of  chloroform  are  more  quickly  produced,  and  also 
subside  more  quickly,  in  children  than  in  adults,  owing,  no  doubt,  to 
the  quicker  breathing  and  circulation.  It  often  happens,  however, 
that  when  the  insensibility  has  been  kept  up  for  some  time,  say 
twenty  minutes  or  half  an  hour,  in  a  child,  it  is  followed  by  a  natu- 
ral sleep  of  a  few  hours'  duration,  provided  there  is  no  painful 
wound  or  other  cause  to  prevent  the  sleep.  I  have  given  chloroform, 
in  a  few  cases,  as  early  as  the  age  of  eight  or  ten  days,  and  in  a  con- 


GENERAL  ANESTHESIA.  449 

siderable  number  of  cases  before  the  age  of  two  months.  And  I 
own  memoranda  of  hundreds  of  cases  under  a  year  old  to  whom  I 
have  administered  this  agent.  There  has  been  no  ill  effect  from  it 
either  in  these  cases  or  in  those  of  children  more  advanced  in  life  ; 
and  it  is  worthy  of  remark  that  none  of  the  accidents  from  chloro- 
form which  have  been  recorded  have  occurred  to  young  children." 

There  is  nothing  peculiar  in  the  effect  of  chloroform  upon  people 
advanced  in  years,  except  that  its  influence  subsides  rather  slowly, 
on  account  of  the  slower  breathing  and  circulation.  I  have  given 
chloroform  to  many  patients  over  seventy-five  years  of  age,  and  to 
one  as  old  as  ninety  years. 

Strength  or  Debility. — "  The  comparative  strength  or  debility 
of  the  patient  has  considerable  influence  on  the  way  in  which  chloro- 
form acts.  Usually  the  more  feeble  the  patient  is,  whether  from  ill- 
ness or  any  other  cause,  the  more  quietly  does  he  become  insensible  ; 
while  if  he  is  strong  and  robust,  there  is  very  likely  to  be  mental 
excitement  in  the  second  degree,  and  rigidity  of  the  muscles,  and 
probably  struggling,  in  the  third  degree  of  narcotism.  Patients  in 
a  state  of  debility  resemble  children,  not  only  in  coming  quietly  and 
easily  under  the  influence  of  chloroform,  but  also  in  the  circumstance 
that  the  common  sensibility  is  suspended  with  less  narcotism  of  the 
nervous  centres  than  is  generally  required  in  robust  persons.  Chil- 
dren, and  persons  in  a  state  of  debility,  have  usually  an  acute  sen- 
sibility, which  causes  them  to  sutfer  pain  from  very  slight  injuries, 
but  this  sensibility  is  more  easily  suspended  by  chloroform  than  the 
less  acute  sensibility  of  robust  persons." 

Hysteria. — "  Patients  who  are  subject  to  hysteria  sometimes 
have  symptoms  of  the  complaint,  such  as  sobbing,  crying,  or  laugh- 
ing, as  soon  as  consciousness  is  suspended,  or  even  impaired,  by  the 
chloroform  ;  but  these  symptoms  can  always  be  subdued  by  pro- 
ceedino-  with  the  inhalation.* 


*  Chloroform  in  hysteria  is,  I  think,  one  of  the  most  valuable  medicines  of 
the  Materia  Medica,  while,  on  the  contrary,  sulphuric  ether  is,  so  far  as  my 
experience  goes,  most  decidedly  objectionable  to  such  patients.  I  have  treated 
females  afflicted  in  this  way  where  ether  had  been  used  by  the  pound  with  no 
other  effect  seemingly  than  increasing,  intensifying,  and  prolonging  the  par- 
oxysm;  yet  with  a  very  few  inhalations  of  cliloroform  I  have  had  the  pleas- 
ure of  seeing  these  persons  fall  into  the  most  natural  slumber,  and  after  rest- 
ing quietly  for  hours,  the  slumber  prolonged,  perhaps,  as  sometimes  has  seemed 
indicated,  by  occasional  repetition  of  the  inhalation,  I  have  seen  them,  again 
and  again,  awake  perfectly  recovered. 

29 


450  ORAL  DISEASES  AND  SURGERY. 

"  In  some  persons  who  are  subject  to  hysteria  the  breathing  be- 
comes excessively  deep  and  rapid  while  inhaling  chloroform.*  This 
usually  occurs  just  as  the  patient  is  becoming  unconscious,  but  in  a 
few  cases  even  earlier,  and  the  patient  is  aware  of  the  impulse  to 
breathe  in  this  manner.  After  this  kind  of  hysterical  breathing  has 
lasted  a  minute,  the  patient  generally  rests  nearly  a  minute  without 
breathing  at  all,  after  which  the  respiration  becomes  generally  very 
natural.  Chloroform  is  to  be  given  very  sparingly  during  the  vio- 
lent breathing,  or  else  withdrawn  altogether  for  a  minute  or  two." 

Pregnancy. — It  is  not  generally  thought  that  there  is  anything 
in  this  condition  objectionable  to  the  use  of  chloroform. 

The  Menstrual  Period. — This  period  is  certainly  not  to  be  pre- 
ferred or  selected  as  an  occasion  of  chloroform  exhibition.  Yet 
there  is  nothing  at  all  in  the  condition  adverse  to  such  exhibition. 
The  controlling  effect  of  the  agent  over  hysterical  symptoms  has  just 
been  remarked,  and  such  irritability  of  the  system  is  the  only  pecu- 
liarity of  this  state.  Indeed,  it  is  very  common  that  the  hysterically 
inclined  female  is  compelled  to  resort  to  chloroform,  particularly  in 
conditions  of  dysraenorrhcea. 

Diseases  of  the  Lungs. — "Affections  of  the  lungs  sometimes 
cause  a  little  difiQculty  and  delay  in  the  administration  of  chloroform, 
as  the  vapor  is  liable  to  excite  coughing  when  the  mucous  membrane 
of  the  air-passages  is  irritable.  The  inconvenience  is,  however,  con- 
fined to  the  time  of  inhalation,  for  the  cough  is  generally  relieved 
afterward. f 

"  I  have  given,"  says  Dr.  Snow,  "  chloroform  for  surgical  purposes 
in  many  cases  where  phthisis  was  present,  and  in  several  patients 
who  had  suffered  from  haemoptysis,  and  have  not  seen  any  ill  effects 
from  its  use  in  these  cases.  Chloroform  has,  indeed,  often  been 
inhaled  with  advantage  to  relieve  the  cough  in  consumption.     The 

*  Dr.  Snow,  in  his  paragraph,  remarks  the  supervening  of  this  condition 
after  the  first  few  inhahitions,  but,  according  to  my  own  experience,  it  is  as 
uncommon  when  chloroform  is  used  as  it  is  common  in  the  employment  of 
ether.  When,  in  administering  ether,  I  see  the  slightest  signs  of  hysteria, 
either  in  male  or  female,  I  always  expect  at  once  to  control  them  by  replacing 
the  ether  with  chloroform.' 

f  This  difiiculty,  as  observed  not  only  by  Dr.  Snow,  but  also  by  nearly 
all  writers  on  anaesthesia,  I  have  found  to  be  almost,  if  indeed  not  entirely, 
obviated  by  preceding  the  exhibition  with  a  tablespoonful  of  thick  mucilage 
of  gum  acacia,  the  patient  allowing  it  gradually  to  lose  itself  over  the  mucous 
surfaces. 


GENERAL  ANESTHESIA.  451 

cases  of  chronic  bronchitis  in  which  chloroform  is  administered  and 
for  surgical  operations  are  still  more  numerous." 

Disease  of  the  Heart. — "  There  is  a  very  general  impression 
that  the  use  of  chloroform  is  unsafe  when  disease  of  the  heart 
exists,  more  particularly  fatty  degeneration  of  that  organ.  This 
belief  has  been  encouraged  by  the  circumstance  that  this  affection 
has  been  present  in  a  few  of  both  the  real  and  alleged  deaths  from 
chloroform,  and  also  by  the  fact  that,  in  the  accidents  that  have  been 
really  due  to  chloroform,  the  heart  has  been  the  organ  on  which  it 
has  exerted  its  fatal  influence.  When  we  come  to  investigate  these 
cases,  however,  we  shall  find  reason  to  conclude  that  the  heart  has 
probably  been  diseased  in  quite  as  great  a  proportion  of  the  patients 
who  have  taken  chloroform  without  ill  effects  as  of  those  who  have 
succumbed  under  its  influence.  As  regards  my  own  practice,"  says 
Dr.  Snow,  "the  only  case  in  which  death  could  in  any  degree  be 
attributed  to  the  chloroform,  was  one  in  which  there  was  extreme 
fatty  degeneration  of  the  heart ;  but,  on  the  other  hand,  I  have 
given  chloroform  in  numerous  cases  without  ill  effect  where  the 
symptoms  of  this,  as  well  as  of  other  affections  of  the  heart,  were 
present  in  a  marked  degree.  Indeed,  I  have  never  declined  to  give 
chloroform  to  a  patient  requiring  a  surgical  operation,  whatever 
might  be  his  condition,  as  I  early  arrived  at  the  conclusion  that  this 
agent,  when  carefully  administered,  causes  less  disturbance  of  the 
heart  and  circulation  than  does  severe  pain.  Wherever,"  continues 
Dr.  Snow,  "  I  have  had  an  opportunity  of  seeing  an  operation  per- 
formed without  chloroform,  I  have  carefully  examined  the  pulse, 
and  although  none  of  these  operations  have  been  of  a  very  severe 
nature,  1  have  found  the  circulation  to  be  much  more  disturbed  than 
it  would  have  been  by  chloroform  carefully  administered.  The  pulse, 
in  most  of  these  cases,  has  been  exceedingly  frequent  during  the 
operation,  and  in  some  instances  it  has  intermitted  to  an  unusual 
extent. 

"  In  one  instance  I  had  an  opportunity  of  witnessing  a  similar 
operation  on  the  same  patient,  first  without  chloroform,  and  after- 
ward under  the  influence  of  the  agent.  In  the  operation,  which  was 
lithotrity,  at  the  first  operation  I  began  to  feel  the  pulse  just  when 
the  patient  saw  the  lithotrite  about  to  be  introduced.  It  was  120  in 
the  minute.  As  soon  as  the  instrument  was  introduced  the  pulse 
increased  to  144,  and  immediately  afterward  it  became  uneven,  irreg- 
ular, and  intermitting.  I  could  not  count  more  than  three  or  four 
beats  at  a  time  ;  and  occasionally,  when  the  pain  seemed  greatest, 


452  ORAL  DISEASES  AND   SURGERY. 

and  the  man  was  straining  and  holding  his  breath,  the  pulse  was 
altogether  absent  for  four  or  five  seconds.  In  order  to  ascertain 
whether  the  absence  of  the  pulse  at  the  wrist  might  not  depend  on 
the  pressure  of  the  muscles  of  the  arms,  caused  bj  grasping  the 
table,  I  applied  my  ear  to  the  chest,  and  found  that  there  was  no 
sound  whatever  to  be  heard  during  the  intervals  when  the  pulse  was 
imperceptible.  It  was  evident  that  the  patient  held  his  breath  till 
the  right  cavities  of  the  heart  became  so  distended  as  to  stop 
the  action  of  the  organ  till  the  respiration  returned.  The  man  did 
not  complain  or  cry  out  during  the  operation. 

"A  week  afterward  the  lithotrity  was  repeated,  but  on  this  occa- 
sion I  administered  chloroform.  The  pulse  was  120  in  the  minute 
when  the  patient  began  to  inhale  the  chloroform,  but  it  became 
slower  as  he  was  made  unconscious,  and  it  was  regular  during  the 
operation.  It  was  only  toward  the  end  of  the  operation,  when  the 
effect  of  the  agent  was  allowed  to  diminish,  and  when  the  man 
began  to  strain  a  little,  though  not  yet  conscious,  that  the  pulse  in- 
termitted slightly,  passing  over  a  single  beat  occasionally.  There 
were  none  of  the  long  intermissions  of  the  pulse  observed  on  the 
former  occasion. 

"  It  is  very  evident  that  if  the  above-mentioned  patient  had  been 
the  subject  of  any  affection  of  the  heart  which  weakened  or  embar- 
rassed its  action,  he  would  have  run  a  much  greater  risk  from  the 
pain  of  the  first  operation  than  from  the  inhalation  of  the  chloroform 
in  the  second  one. 

"In  a  few  of  the  patients  having  the  arcus  senilis  of  the  cornea, 
a  weak,  intermitting,  or  irregular  pulse,  and  other  signs  of  fatty 
degeneration  of  the  heart,  there  have  been  a  feeling  of  faintness  and 
a  tendency  to  syncope  as  the  effects  of  the  chloroform  were  sub- 
siding, especially  when  the  operation  had  been  performed  in  the  sit- 
ting position;  but  these  symptoms  have  soon  subsided,  in  all  cases 
I  have  met  with,  on  placing  the  patient  horizontally,  with,  or  with- 
out, the  help  of  a  little  ammonia  to  the  nostrils." 

Cerebral  Diseases. — "Affections  of  the  head  offer  no  obstacle 
to  the  administration  of  chloroform.  I  have  given  it  to  several 
patients  who  had  suffered  previously  from  an  attack  of  apoplexy; 
some  of  them  still  retained  the  paralysis  resulting  from  the  attack, 
but  the  chloroform  has  not  been  attended  or  followed  by  ill  effects 
in  any  of  these  cases." 

The  following  interesting  and  most  instructive  case  is  mentioned 
in  this  direction  : 


GENERAL  ANESTHESIA.  453 

"  The  31st  of  October  was  a  day  appointed  by  Mr  Fergusson  to 
perform  lithotrity  on  a  gentleman  seventy-eight  years  of  age,  who 
had  a  phosphatic  calculus  in  his  bladder.  He  was  a  patient  of  Mr. 
Propert,  and  Mr.  Fergusson  had  removed  a  similar  calculus  by  litho- 
trity, and  I  had  given  him  chloroform  at  each  of  the  operations,  and 
it  was  arranged  that  he  should  have  chloroform  on  the  present  occa- 
sion. Mr.  Propert  informed  Mr.  Fergusson  and  myself  on  our  arrival 
that  his  patient  had,  the  night  before,  an  attack  resembling  apoplexy ; 
he  had  been  insensible  ;  the  breathing  had  been  stertorous,  the  pupils 
dilated,  and  the  face  very  red  and  congested.  Mr.  Propert  had 
caused  him  to  be  cupped  to  fourteen  ounces,  and  had  given  him 
twenty  grains  of  calomel  in  the  course  of  the  night,  and  in  the 
morning  he  was  as  usual,  and  remained  so  at  the  time  of  our  visit. 
We  considered  the  case  with  Mr.  Propert,  and,  as  there  were  reasons 
for  not  postponing  the  operation,  it  was  determined  that  he  should 
inhale  the  chloroform  rather  than  be  subjected  to  the  pain.  The 
vapor  acted  very  favorably  :  he  recovered  his  consciousness  a  few 
minutes  after  the  operation,  and  expressed  himself  as  feeling  quite 
well." 

Insanity. — Chloroform  acts  on  insane  patients  just  as  it  does  on 
others  :  when  the  effects  subside  they  are  in  the  same  state  of  mind 
as  before.  Mr.  Snow  remarks  the  suspiciousness  of  the  insane,  but 
gives  his  experience  where  teeth  have  been  extracted  and  other 
operations  performed  which  it  would  have  been  impossible  to  ac- 
complish in  the  same  individual  without  resorting  to  inhalation. 
The  employment  of  chloroform  in  the  delirium  of  mania  a  potu  has, 
through  the  experiments  of  Dr.  Ely  McClellan,  of  the  United  States 
Army,  lately  been  revived,  and  commanded  much  attention,  the 
successes  of  this  gentleman  having  been  sufficiently  verified  by 
practitioners  in  every  part  of  the  country:  given  in  drachm  doses, 
pro  re  naia,  it  seems  completely  to  break  the  paroxysm,  causing 
the  patient  to  fall  into  profound  sleep,  from  which,  after  eight  or 
ten  hours,  he  commonly  awakes  entirely  relieved.  In  delirium, 
however,  the  chloroform  is  to  be  taken  into  the  stomach,  and  not 
breathed. 

I  may  close  this  consideration  of  chloroform  by  again  remarking, 
as  alluded  to  in  the  commencement  of  the  chapter,  that  the  agent, 
if  one  feels  justified  in  using  it,  is  far  to  be  preferred  in  oral  surgery 
to  the  ether;  a  profound  impression  created  through  chloroform  will 
not  unfrequently  continue  through  quite  a  prolonged  operation ;  or, 
if  it  be  necessary  to  renew  the  inhalation,  the  desired  impression 


454  ORAL  DISEASES  AND  SURGERY. 

is  generally  made  with  great  rapidity.  Operations  about  the  mouth, 
unlike  most  other  surgical  services,  require  to  be  executed  with 
great  rapidity  ;  therefore  is  it  a  necessity  to  be  as  little  interfered 
with  as  possible:  an  impression,  apparently  very  profound,  made 
with  ether,  is  apt  to  be  broken  in  the  very  first  shock  of  an  oral 
operation.  This  first  step  may  be  of  a  character  starting,  in  some 
instances,  frightful  hemorrhage,  and  which  can  be  combated  only 
at  the  completion  of  the  operation  ;  to  have  a  patient  pass  from  con- 
trol at  such  a  moment,  and  under  such  circumstances,  is  sometimes 
a  matter  of  serious  concern.  If  one  has  not  used  chloroform  up  to 
this  time,  and  the  article  is  at  all  convenient,  it  is  very  apt  to  be 
given  to  the  patient  in  a  quite  free  manner.  I  certainly  do  desire 
heartily  to  recommend  it,  but  prefer,  as  my  own  practice  is  con- 
cerned, to  combine  it  in  varying  proportions  with  sulphuric  ether. 
I  have  in  this  chapter  used  in  many  instances  the  strong  authori- 
tative experiences  of  Dr.  Snow.  I  am  convinced  of  the  truth  of  all 
that  he  maintains;  his  experience  with  the  agent  has  certainly  been 
of  the  most  extensive  nature:  personally,  however,  I  am  still  afraid 
to  use  chloroform  except  in  conjunction  with  ether  ;  and  while  such 
fear  may  not  be  well  grounded,  yet,  as  it  exists,  I  cannot  do  other- 
wise than  give  expression  to  it.  At  this  day  it  were  certainly  idle 
to  attempt  to  deny  that  many  deaths  have  resulted  from  the  use  of 
chloroform  ;  and  a  large  proportion  of  these  accidents  have  occurred 
in  the  hands  of  eminent  and  skillful  men,  and  where  every  possible 
scientific  precaution  had  been  taken. 

Again,  the  accidents  have  seldom  or  never  been  traceable  to  an 
overdose  of  the  agent;  the  deaths  have  never  occurred  from  narco- 
tism, but  from  direct,  immediate,  and  unforeseeable  paralysis  of  the 
heart.  I  have  not  overlooked  the  fact  that  fatal  results  happening 
while  chloroform  was  being  used  might  not  be  owing  to  this  agent. 
Certainly  there  are  cases  enough  on  record  justifying  such  a  conclu- 
sion,— cases  with  which  every  surgeon  must  be  familiar;  but,  on 
the  other  hand,  there  are  instances  of  such  doubt,  or  perhaps  I 
should  rather  say,  of  such  certainty,  that  one  may  incline  to  err  on 
the  side  of  discretion. 


NITROUS  OXIDE  GAS. 

Except  as  its  use  in  such  speedily-performed  operations  as  the 
extraction  of  teeth  is  concerned,  it  would  not  seem  that  nitrous 
oxide  will  ever  be  found  applicable  to  oral  operations  (at  least,  as 


GENERAL  ANESTHESIA.  .  455 

at  present  we  know  how  to  get  the  effects  of  the  agent).  In  this 
opinion,  I  am  aware,  others  may  not  feel  disposed  to  agree  with  me, 
and  it  may  very  well  be  that  I  am  wrong,  as  I  have  had  little  ex- 
perience with  the  agent.  Be  this  as  it  may,  however,  ether  and 
chloroform  appear  so  satisfactory,  and  every  way  reliable,  and  at 
the  same  time  are  so  convenient  of  use  as  compared  with  the  gas, 
that  I  imagine  they  will  continue  to  hold  the  supremacy. 

Should  it  be  felt  by  any  experienced  in  such  matters  that  the  pro- 
toxide of  nitrogen  as  an  anaesthetic  possesses  advantages  over  ether 
and  the  chloric-ether,  they  will  hail  with  satisfaction  the  lately  per- 
fected attempt  to  furnish  the  substance  in  liquid  form.  A  convenience 
called  the  "  Surgeon's  Case"  is  now  to  be  procured,  in  which  in  a 
cylinder  one  foot  long  by  three  inches  in  diameter  are  stored  by 
compression  one  hundred  gallons  of  the  gas.  This  cylinder  is 
refilled  at  the  depot  as  may  be  required.  The  other  contents  of  the 
case  are  the  constituents  of  the  required  inhaling  apparatus, — the 
rubber  bag,  tubing,  and  mouth-piece.  The  whole  weight  of  the  case 
and  contents  is  fifteen  pounds.*  It  is  a  neat  arrangement,  and 
highly  recommends  itself. 


*The  subject  of  nitrous  oxide  will  be  found  considered  with  a  fullness 
which  may  be  said  to  be  exhaustive,  in  several  elaborate  essays,  written 
respectively  by  Drs,  George  J.  Ziegler,  Geo.  T,  Barker,  and  F.  R,  Thomas, 
of  Philadelphia. 


CHAPTER    XX. 


ARTIFICIAL   DENTURES. 


PIVOT  TEETH. 


Passing  to  the  consideration  of  a  mouth  in  which  certain  teeth, 
or  it  may  be  the  whole  denture,  have  l)een  lost,  the  surgeon,  having 
the  assistance  of  a  mechanical  dentist,  finds  it  in  his  province  to 
consider  the  replacement  of  the  lost  organs. 

Lost  natural  teeth  are  replaced,  either  through  the  pivoting  of 
crowns  upon  healthy  roots  which  may  remain,  or  by  adjusting  the 
substitutes  to  plates  of  various  kinds. 

Pivot  Teeth. — The  pivoting  of  a  crown  to  a  root  (Fig.  186)  is  an 
operation  which  has  its  commendation  or  condemnation 
in  the 'features  of  each  particular  case.  It  is  to  be  ac- 
cepted as  a  cardinal  principle  that  only  the  perfectly- 
vital  healthy  root  is  able  to  support  an  artificial  crown. 
Pivot  teeth  are  found  most  useful  and  satisfactory 
when  confined  to  the  six  anterior  roots,  superior  or 
inferior, — the  incisors,  central  and  lateral,  and  the  cus- 
pidati ;  although,  except  where  bifurcation  or  great  flat- 
ness may  exist  very  near  the  neck,  they  are  frequently 
attached  to  the  roots  of  the  bicuspidati.  The  incisor 
Crown  pivoted       ^    howcvcr,  are  those  to  which  these  crowns  are  pre- 

to  root.  '  '  * 

eminently  adapted,  and  to  which  it  may  prove  as  well 
to  confine  them  as  closely  as  circumstances  shall  permit. 

Pivot  teeth  are  always  to  be  considered  as  promising  most  useful- 
ness  and  stability  when  possessed  of  lateral  support  by  the  presence 
of  contiguous  natural  teeth  :  hence  it  is  that  while  one  or  two  of 
such  teeth  having  an  alternate  relation  with  intervening  natural 
organs  will  be  found — cseteris  paribus — to  answer  excellent  ends, 
where  three  or  four  are  required  contiguously,  experience  demon- 
strates that  it  is  better  to  employ  a  plate. 

Satisfied  of  the  desirability  of  using  a  pivot  tooth,  and  of  the 
(456) 


ARTIFICIAL  DENTURES.  457 

ability  of  a  root  to  support  a  crown,*  the  first  steps  In  an  operation 
consist  In  such  cutting  and  filing  manipulation  as  pertains  to  a 
jointure  between  the  two  parts,  and  In  a  reaming  out  of  the  pulp 
canal  for  the  reception  of  the  pivot. 

A  case  presenting  Itself  as  a  pivoting  operation  will  commonly  be 
found  in  the  condition  of  a  half-destroyed  crown  with  a  pulp  dead, 
or,  it  may  be,  only  serai-devitalized.  The  latter  condition  of  the  pulp 
existing,  a  first  step  will  reside  in  its  destruction.  To  accomplish  this, 
as  little  disturbance  as  possible  is  to  be  provoked.  If  such  pulp  be 
exposed,  the  very  best  plan  to  pursue  is  to  prick  into  it,  with  any 
convenient  needle-pointed  instrument,  arsenic  and  atropia,  equal  parts 
of  which  have  been  rubbed  up  in  creasote.  From  a  tooth  in  my  own 
mouth  I  have  had  such  a  semi-devitalized  pulp  removed  in  the  space 
of  fifteen  minutes.  It  is  done  without  pain,  and  is  a  simple  opera- 
tion which  may  be  repeated  by  any  person  who  possesses  sufficient 
delicacy  of  touch.  A  pulp  so  treated  limits  irritation  to  the  closest 
confines.  When  the  pricking  instrument  is  felt  to  strike  against  the 
foramen  of  the  root  and  sensibility  is  lost,  It  is  only  necessary  to 
introduce  a  barbed  broach,  and,  by  a  few  turns  in  the  canal,  the 
mangled  pulp  is  caught  and  withdrawn. 

In  a  broken  tooth  where  a  cavity  of  decay  does  not  expose  the 
pulp,  such  exposure  may  be  made  by  delicate  manipulation  with  the 
drill  or  excavator,  or  otherwise  it  is  to  be  treated  by  the  introduc- 
tion of  the  arsenical  preparation  into  the  existing  cavity,  and  the 
sealing  up  of  the  same  for  a  period  varying  from  twelve  to  twenty- 
four  hours,  according  to  the  density  of  the  tooth.  A  piece  the  size 
of  an  ordinary  pin-head  will  be  found  sufficient  to  destroy  a  pulp. 
The  pulp  thus  destroyed,  the  crown  of  the  tooth  may  be  cut  off",  as 
now  to  be  described.  A  previous  mention,  however,  is  to  be  made 
of  those  accidents,  not  uncommon,  which  have  caused  the  fracture 
of  a  perfectly  healthy  tooth.  If  in  such  cases,  as  is  most  likely, 
the  shock  has  excited  pulpitis,  and,  it  may  be,  periodontitis,  a  first 
attention  is  to  be  directed  to  the  resolution  of  such  conditions.  No 
immediate  attempt  is  to  be  made  to  destroy  the  pulp,  unless  indeed 
it  be  exposed,  when  it  is  to  be  pricked  as  before  described ;  but  a 
local  vigorous  antiphlogistic  treatment  is  to  be  instituted  and  con- 
tinued until  the  practitioner  is  satisfied  that  resolution  is  not  to 
be  effected.  Quiet  secured,  the  broken  tooth  is  allowed  to  remain 
strictly  at  rest  until  all  irritability  has  subsided,  when  a  spear  drill 

*  It  is  not  to  be  understood  that  an  attempt  is  not  to  be  made  to  restore 
an  unhealthy  root  to  the  healthy  state. 


458  ORAL  DISEASES  AND  SURGERY. 

is  to  be  used  for  the  production  of  a  receiving  cavity  into  M^hich  the 
arsenious  paste  is  to  be  applied  as  before  directed.  Another  way 
to  eruploy  the  paste  with  such  broken  teeth  is  to  build  about  the 
edges  of  the  fracture  a  ring  of  gutta-percha,  to  be  accomplished  by 
trailing  a  solution  which  has  been  made  by  covering  parings  of 
gutta-percha  with  chloroform  ;  the  chloroform,  quickly  evaporating, 
leaves  the  gutta-percha  firmly  adherent  to  the  parts  upon  which  it 
has  been  laid.  Within  the  ring  thus  secured,  the  paste  is  to  be  laid 
and  covered  in  with  the  same  solution.  Teeth  from  the  accident  of 
fracture  are  sometimes  made  so  sensitive  as  to  render  it  impossible 
to  use  the  drill.  The  means  just  suggested  will  meet  the  indication. 

If  the  gutta-percha  should  be  found  not  to  adhere  with  sufficient 
tenacity  by  this  method,  it  will  be  necessary  to  excavate  a  groove 
in  the  face  of  the  denture,  and,  after  thoroughly  drying  the  parts, 
build  on  piece  by  piece  the  ring  of  "  Hill  Stopping,"  or  red  gutta- 
percha, when  the  paste  may  be  placed  in  position  and  covered  with 
a  portion  of  the  same  material. 

Sometimes  it  is  found  also  to  happen  that  nodules  of  secondary 
dentine  exist  in  the  pulp,  interfering  with  the  absorption  of  the 
arsenic;  in  such  cases  it  will  be  necessary  to  repeat  the  application 
a  number  of  times,  or  else  expose  the  organ  and  prick  it.  Resistance 
to  arsenical  applications  is  quite  diagnostic  of  the  presence  of  pulp 
nodules.     (See  chapter  on  Odontalgia.) 

To  cut  the  crown  from  a  root,  the  first  instrument  required  is  the 
excising  forceps.      This  is  used  in  anticipation  of  the  file,  the  crown 

Fig.  187. — Upper  Excising  Forceps. 


being  cut  away  little  by  little  until  the  neck  is  uncovered.  This 
extent  of  excision  being  accomplished,  it  is  prudent  to  give  the  part 
a  rest  of  a  day  or  two ;  it  is  a  safe  plan,  although  certainly  not  in 
all  cases,  or  indeed  even  in  the  majority,  a  necessity. 

In  place  of  the  forceps  some  operators  prefer  the  saw  for  excising 
a  crown  ;  it  will  not,  as  a  rule,  be  found  so  convenient  of  employ- 
ment, and  is  more  apt  to  provoke  inflammatory  response.  It  is  not 
amiss,  however,  to  have  such  an  instrument,  as  occasionally  it  will 
be  found  quite  useful. 


ARTIFICIAL  DENTURES. 

Fig.  188. — Saw  for  Excising  Crown. 


459 


Fig.   189.— 
Pivot  Filks. 


Following  the  excising  forceps  is  the  pivot  file.  This  instrument, 
being  half  round,  cuts  a  concave  face  on  the  neck  of  the  root, 
which  aspect  of  face  is  seen  to  correspond  with  the 
accommodation  required  by  the  neck  face  of  the 
artificial  crown,  which,  as  it  comes  from  the  labor- 
atory, and  is  used,  is  convex. 

In  filing  down  the  natural  root,  the  most  judicious 
gentleness  is  to  be  combined  with  the  necessary 
dispatch.  The  file  used  at  first  should  be  sharp,  so 
as  to  accomplish  the  required  amount  of  work  with 
the  least  irritation,  and  should  be  used  until  the 
gum  is  fairly  touched ;  the  sharp  file  is  then  to 
be  exchanged  for  a  comparatively  dull  one,  with 
which  the  now  concave  face  of  the  root  should  be 
smoothed  until  a  marked  bleeding  from  the  gum 
occurs  all  around  the  root.  The  object  of  this  is  to 
insure  an  accurate  covering  of  the  joint  between 
root  and  pivot  tooth  by  the  healed  gum.  It  is 
sometimes,  though  very  rarely,  the  case  that  with 
previously  irritated  roots  this  preparatory  opera- 
tion should  be  divided  into  several  sittings,  mean- 
while pursuing  antiphlogistic  treatment ;  but  the 
cutting  with  the  dull  file  which  is  to  take  off  the 
root  below  the  gum  is  to  be  the  step  immediately 
preceding  the  attachment  of  the  new  crown-,  other- 
wise the  gum  will  be  found  to  fall  over  the  root 
and  thus  partially  cover  its  surface. 

During  the  process  of  cutting  down  the  natural 
crown,  or,  to  make  a  rule,  we  may  say  at  that  stage 
which  is  to  employ  the  dull  file,  the  preparation  of 
the  canal  is  to  claim  attention.  To  effect  the  re- 
quirements here  demanded,  rose  or  bur  drills  of 
various  sizes  may  be  employed,  commencing  with 
one  received  into  the  natural  canal,  and  increasing 
seriatim  until  a  sufficient  diameter  is  secured, — 
such  diameter  being  in  correspondence  with  the  size 
of  the  pivot  used.  The  depth  to  which  a  canal  may 
be  reamed,  and  also  the  diameter,  depend  upon 


460  ORAL  DISEASES  AND   SURGERY. 

the  size  and  density  of  the  root ;  a  rule  applicable  to  all  cases  can- 
not be  given  :  it  is  to  be  deemed  necessary,  however,  that  sufficient 
circumference  and  depth  be  secured  to  insure  the  retention  of  the 
pivot;  half  the  length  of  a  root  may  commonly  be  reamed  with 
impunity. 

The  process  of  reaming  completed,  a  delicate  spear  drill  is  to  be 
passed  into  the  continuation  of  the  canal,  and  the  parts  cleansed  to 
the  apex.  This  secondary  canal  is  then  to  be  filled  with  gold  (see 
Filling  Pulp  Canal)  ;  this  accomplished,  the  root  is  ready  for  the 
crown. 

The  selection  of  a  crown  for  the  root  considers — first,  the  shade  or 
color,  which  is  to  correspond  with  that  of  the  neighboring  teeth  ; 
second,  the  shape  and  adaptability  of  the  crown.  By  having  in 
one's  possession  a  few  hundred  artificial  crowns,  it  is  quite  pos- 
sible to  find  among  them  many  of  such  perfect  match  as  to  render 
the  slightest  alteration  unnecessary.  Third,  it  is  requisite  to  have 
the  pivot  canal  in  the  crown  and  that  in  the  root  so  correspond  that 
when  the  jointure  is  made  the  crown  occupies  its  right  position. 
To  be  satisfied  of  such  proper  relation  of  parts,  the  crown  and  root 
may  be  put  together  for  the  moment  with  a  pivot  of  round  match- 
stick.  It  is  suggested,  and  practiced  by  some,  that  when  there  is 
lack  of  natural  correspondence  in  the  canal  of  the  root,  the  required 
direction  shall  be  given  by  the  drill:  this,  however,  is  to  be  con- 
demned as  bad  practice ;  it  is  much  better  to  seek  a  new  crown. 

To  have  an  accurate  adaptation  of  the  crown  to  the  root  is  most 
desirable  :  this  may  require  some  grinding  of  the  crown  ;  and  to  know 
just  where  to  grind  makes  it  necessary  that  the  touching  points  be 
recognized.  Such  information  may  be  secured  by  coating  the  surface 
with  a  film  of  wax  ;  putting  the  parts  now  together,  the  wax  over- 
Pjq  J9Q  lying  the    points  implicated  will,  of 

course,  be  found  indented  and  dis- 
placed. A  plan  even  better  than  that 
just  described  is,  immediately  upon 
having  the  root  prepared,  to  take  an 
impression  of  it  and  the  contiguous 
teeth  in  wax  (see  Taking  Impres- 
sions), and,  having  made  a  model  of 
plaster  of  Paris,  fit  the  crown  to  the 

Hand-Lathe.  modpl 

To  grind  a  tooth,  a  stick  of  corundum  is  used  by  many.  Such 
sticks  are  to  be  procured  at  the  furnishing  depots  for  a  few  cents. 


ARTIFICIAL  DENTURES. 


461 


Fig.  191. 


A  better  means  is  found,  however,  in  the  employment  of  a  lathe; 
of  these  instruments  the  greatest  variety  is  offered.  The  smallest 
hand-lathe,  however,  is  commonly  found  sufficient  to  meet  all  the 
requirements.  Fig.  190  represents  such  a  lathe:  it  may  be  attached 
temporarily  to  any  stand  conveniently  at  hand.  This  lathe  is  entirely 
noiseless.  Having  neither  cog-wheels  nor  belt,  it  is  free  from  oil, 
dirt,  and  thef  trouble  of  adjustment.  The  motive  power  is  commu- 
nicated by  friction  gained  by  covering  the  small  wheel,  or  pulley, 
with  a  rubber  ring  which  comes  in  contact  with  the  inner  surface 
of  the  driving-wheel.  The  driving-wheel  is  six  and  a  half  inches  in 
diameter;  the  small  wheel,  two  inches  in  diameter;  and  the  weight 
of  the  lathe  is  two  and  three-quarter  pounds. 

A  form  of  lathe  which,  being  worked  by 
the  foot,  leaves  both  hands  at  liberty,  is  repre- 
sented in  Fig.  191.  Such  a  lathe  is  in  many 
respects  preferable  to  the  first:  it  is  certainly 
more  convenient  to  the  operator.  This  lathe 
has  a  movable  column  and  table,  and  is 
capable  of  being  elevated  eight  inches:  it  is 
made  to  accommodate  the  operator  in  either  a 
sitting  or  a  standing  posture. 

As  the  grinding  instrument,  wheels  of  corun- 
dum are  used  on  these  lathes ;  the  surgeon 
should  provide  himself  with  five  or  six  of  these 
wheels,  of  varying  sizes. 

Crown  and  root  prepared,  the  pivot  is  the 
next  consideration. 

A  pivot  is  made  either  of  wood  or  metal. 
A   wood  pivot  is  only  to  be   made  of  thor-  Foot-Lathe. 

oughly-seasoned  and  firmly-compressed  hick 

cry:  a  box  of  such  pivot  sticks,  which  maybe  purchased  at  a  depot  at  a 
cost  of  twenty-five  cents,  will  set  hundreds  of  teeth  ;  it  is  best  thus  to 
provide  one's  self.  To  use  the  wood  pivot,  the  operator  commences 
by  securing  the  exact  length  required:  this  he  learns  with  least 
trouble  from  his  temporary  pivot  of  match-stick.  One  end  of  this 
pivot  is  now  fitted  into  the  crown,  the  other  being  of  a  size  corre- 
sponding with  the  canal  in  the  root.  Everything  being  thus  pre- 
pared, it  only  remains  to  put  the  two  together,  and  the  operation  is 
completed. 

It  will  occasionally,  however,  be  found  to  happen  that,  in  defiance 
of  the  nicest  care  which  may  have  been  exercised,  there  is  slight 


462  ORAL  DISEASES  AND  SURGERY. 

fault  in  the  articulation  of  the  cutting  edge  of  the  new  crown  with 
the  corresponding  teeth  of  the  lower  jaw:  this  is  commonly  most 
easily  remedied  by  filing  away  the  impinging  point  on  the  natural 
tooth,  or  with  the  corundum  stick  it  may  be  taken  from  the  artificial 
crown. 

A  second  and  much  more  serious  complication  is  periodonteal  in- 
flammation, the  root  becoming  sore  and  painful.  When  such  inflam- 
mation supervenes,  it  is  to  receive  at  once  the  required  attention. 
(See  Periodontitis.) 

Metal  pivots  are  variously  used.  A  common  plan  is  to  make  a 
delicate  tube  of  gold  of  such  size  as  will  permit  its  introduction  into 
the  drilled  opening  of  the  root  (which  in  these  cases  should  be  made 
somewhat  larger  than  is  required  for  wooden  pin  pivoting,  and 
should  be  bell-mouthed),  leaving  suflBcient  space  around  it  to  fill 
solidly  with  foil.  A  wire  fitting  this  tube  should  be  inserted  into  it 
to  prevent  its  compression,  and  it  should  then  be  filled  into  posi- 
tion. The  wire  is  then  withdrawn,  the  tube  filled  either  with  wood 
or  gutta-percha  to  prevent  its  injury,  and  the  face  of  gold  filed  con- 
cave as  though  it  were  tooth  structure  ;  tliis  leaves  only  a  ring  of 
cementum  exposed,  thus  efl'ecting,  from  the  exceeding  durability  of 
this  substance,  a  very  permanent  and  desirable  result.  An  impres- 
sion is  now  taken  in  wax,  a  plaster  cast  is  made,  and  from  this, 
metal  dies.  A  thin  plate  of  gold  is  now  struck  between  these  dies, 
fitting  accurately  the  face  of  the  root,  being  filed  to  the  exact  shape 
of  the  face  and  outlines  of  circumference.  Next,  the  plate  of  gold — 
the  cap  having  a  hole  drilled  through  its  centre  corresponding  with 
the  tube  in  the  canal — being  laid  in  place,  a  piece  of  gold  pivot- 
wire  is  passed  through  it  into  its  place  in  the  tube,  and  secured 
with  a  small  piece  of  adhesive  wax.  Cap  and  pin  are  now  removed, 
invested  in  plaster  of  Paris,  and  the  two  soldered  firmly  together. 
The  tooth  here  to  be  used  is  what  is  known  as  a  plate  tooth, — a 
tooth  having  pins  of  platina  in  its  back.  Selecting  a  tooth  of  this 
class  to  suit  the  case,  the  cap  and  pivot  are  slipped  into  place,  and 
the  crown,  held  in  the  exact  position  required,  is  fixed  by  a  particle 
of  wax.  The  whole  piece  thus  joined  together  is  now  removed  from 
the  mouth  :  this  is  accomplished  by  inserting  the  blade  of  an  exca- 
vator beneath  the  plate,  and  thus  lifting  it.  The  tooth  is  backed  by 
a  plate  of  gold  having  holes  punched  for  the  passage  of  the  pins ; 
backing,  tooth,  and  cap  are  now  soldered  together,  and  the  fixture 
is  completed,  requiring  only  to  be  cleaned  and  introduced  into  the 
tube.  If  all  is  as  desired,  the  gold  pivot  should  then  be  tapped  later- 


ARTIFICIAL  DENTURES.  463 

ally  very  gently  with  a  pivoting  hammer,  when  it  will  be  found, 
upon  introduction,  to  remain  with  all  necessary  firmness. 

In  a  case  such  as  just  described  it  is  not  necessary  that  the 
surgeon  do  the  mechanical  work  of  swaging  plates  and  soldering; 
— all  this  is  indeed  more  in  the  province  of  the  mechanical  dentist, 
and  to  him  it  would  seem  proper  and  desirable  to  intrust  it ;  that 
he  accomplish  it  satisfactorily  it  is  only  necessary  to  furnish  him 
with  the  wax  impression  and  the  crown  selected.  Indeed,  as  we  go 
on  it  will  be  seen  that  the  accomplished  mechanical  dentist  is  as 
necessary  to  the  oral  surgeon  as  is  the  mechanician  to  a  general 
practitioner. 

An  improvement,  as  it  is  thought  by  some,  on  the  plan  just  de- 
scribed, consists  in  the  replacing  of  the  root  tube  by  a  hollow  screw, 
a  screw-tap  being  used  to  cut  the  thread  on  its  inner  wall ;  this 
screw,  fixed  in  its  place,  is  to  be  leveled  with  the  face  of  the  root 
and  the  operation  completed  as  already  described. 

In  roots  having  canals  not  in  correspondence  with  the  position 
demanded  for  the  new  crown,  the  mode  of  using  caps  for  the  attach- 
ment of  the  new  crown  seems  to  afford  all  that  can  be  desired,  inas- 
much as  when  teeth  are  thus  pivoted  a  correspondence  between  the 
canals  of  root  and  crown  is  of  no  imj^ortance. 

A  condition  indorsing  most  fully  the  employment  of  the  tube  is 
found  in  such  roots  as  are  somewhat  decayed.  Here,  the  tube  being 
in  place,  after  excavation  of  the  part,  as  in  any  case  of  caries,  it 
is  solidly  built  in  situ  by  a  plug  of  adhesive  gold.  It  is  not  the 
case,  however,  as  is  often  affirmed,  that  this  is  the  only  mode  of 
pivoting  that  may  here  be  employed,  since  Dr.  J.  D.  White,  the 
eminent  dentist,  has  fully  and  practically  shown  that  to  use  the 
common  wood  pivot  it  is  only  necessary  to  ream  a  first  canal  of  a 
size  which  takes  in  this  decay  and  removes  it,  and  from  such  first 
circumference  to  make  a  second  of  the  ordinary  character.  Of 
course  the  pivot  has  a  double  diameter  to  correspond. 

A  plan  of  pivoting  which  is  to  be  considered  a  combination  of 
the  plans  just  described,  consists  in  passing  through  the  centre  of  a 
wood  pivot,  which  has  been  drilled  out  for  the  purpose,  a  second 
pivot  of  gold  wire  ;  such  wire  is  found  materially  to  strengthen 
the  wood,  and  is  thought  by  many  to  be  the  most  desirable  pivot 
that  can  be  employed. 

Still  another  plan  is  the  employment  of  what  is  known  as  the 
vulcanized  pivot.  This  process  is  as  follows.  The  root  being  pre- 
pared as  previously  described,  by  tubing,  a  wire  of  length  sufficient 


464  OBAL  DISEASES  AND   SURGERY. 

to  protrude  one-eighth  of  an  inch  or  so  beyond  this  tubing  is  flat- 
tened at  one  end  and  inserted  into  the  tube;  a  tooth  (usually  a 
"  vulcanite  tooth")  is  adapted  and  placed  in  position  ;  the  wire  and 
tooth  are  next  joined  together  with  adhesive  wax,  and  while  yet 
warm  are  placed  again  accurately  into  position ;  the  wax  pressed 
against  the  root  face  is  cooled  by  jetting  a  stream  of  cold  water  upon 
it  from  a  mouth-syringe,  and  the  tooth,  wax,  and  pin  are  carefully 
withdrawn.  Moulds  are  then  made  of  plaster  as  for  vulcanite  work, 
the  wax  is  removed,  vulcanizable  rubber  is  introduced  in  its  place, 
and  the  pin  and  tooth  are  secured  firmly  together  by  the  vulcanizing 
process;  the  rubber  is  then  filed  and  polished.  This  is  a  very  neat, 
easy,  and  altogether,  as  thought  by  many,  desirable  operation. 

A  hieans  of  setting  a  pivot  tooth  founded  on  the  ease  with  which 
the  Mack  screws  may  be  worked,  and  applicable  particularly  to 
bicuspid  and  even  molar  teeth,  consists  in  inserting  into  the  pre- 
pared face  three  or  more  of  the  screws,  and,  having  a  tooth  prepared 
for  the  purpose,  of  a  box-like  character,  the  chamber  is  filled  with 
cement  plombe,  or  any  of  the  oxychloride  preparations,  and  while  the 
material  is  soft  the  tooth  is  put  into  place,  being  retained  by  the 
fingers  until  the  cement  hardens  about  the  pins.  A  box  tooth  may 
easily  be  made  by  soldering  a  metal  chamber  to  the  pins  of  an  ordi- 
nary plate  tooth. 

Another  plan,  pertaining,  however,  only  to  the  treatment  of 
the  root  where  this  has  been  weakened  by  decay,  consists  in  first 
making  proper  excavation  of  the  diseased  dentine  and  replacing  it 
with  oxychloride  or  amalgam.  The  material  used  having  set,  a 
pivot  canal  is  reamed  in  its  centre,  and  the  operation  completed  by 
the  use  of  the  wood  or  wire-wooded  pivot.  Such  mode  of  treating 
a  decayed  root  is  not,  however,  to  be  commended,  as  it  takes  but 
very  little  experience  to  demonstrate.  A  pivot  inserted  in  osteo- 
dentine  so  exposed  could  have  no  permanency;  while  a  periosteal 
degeneration — indeed,  a  necrosis  of  the  root,  quite  as  adverse — is 
almost  certain  to  associate  itself  with  the  use  of  the  amalgam. 

A  method  of  setting  a  plate  tooth  on  a  root,  and  giving  an  addi- 
tional support  by  a  rim  of  gold,  which  certainly  has  the  merit  of 
originality,  is  thus  described  by  H.  E.  Dennet,  of  Massachusetts : 

"First  cut  the  crown  ofif;  then  tunnel  out  the  root,  by  enlarging 
the  pulp  cavity,  making  it  very  large  at  the  orifice,  and  smaller  as  it 
goes  in,  making  retaining  points  at  proper  places. 

"  Solder  a  platina  point  to  a  suitable  plate  tooth,  the  point  being 
large  where  it  is  soldered,  and  a  gradual  taper  bringing  it  nearly  to 


ARTIFICIAL  DENTURES.  465 

a  point;  then  make  it  barbed  or  rough,  so  that  it  will  not  pull  out 
after  the  tooth  is  set. 

"Having  prepared  the  root  and  the  tooth,  put  on  the  rubber  dam  ; 
fill  the  root  to  the  point  where  the  end  of  the  pivot  will  meet  it;  put 
on  the  tooth,  and  fill  around  the  pivot  (turning  the  tooth  in  and  out, 
and  laterally,  as  convenience  requires,  the  pivot  being  easily  bent 
without  danger  of  breaking);  build  out  to  the  natural  form  of  the 
tooth,  using  first  soft  gold,  then  that  which  is  partially  adhesive, 
then  adhesive." 

"The  writer  of  the  above,"  ssvys  Dr.  J.  H.  McQuillen,  "placed 
in  my  hands  the  root  of  a  tooth,  with  a  plate  tooth  attached  in  the 
manner  described.  The  operation  was  very  skillfully  performed,  and 
the  plan  proposed  is  certainly  preferable  to  building  out  a  golden 
crown,  which,  however  perfectly  executed,  cannot  be  said  to  add  a 
charm  to  the  smile  of  beauty,  although  it  may  prove  useful  in  mas- 
tication." 

The  restoration  of  partly-fractured  crowns  is  an  operation  which, 
as  belonging  to  the  front  teeth,  would  seem  to  be  worthy  of  more 
attention  than  it  has  heretofore  received.  As  an  example  in  such 
direction  of  what  may  be  accomplished,  the  following  case  from  the 
practice  of  Chas.  J.  Essig,  D.D.S.,  is  well  worthy  of  being  quoted: 

"The  patient,  a  student  of  the  Philadelphia  Dental  College,  had 
the  misfortune,  ten  years  back,  to  break  off,  by  a  fall,  about  two- 
thirds  of  his  right  central  incisor;  in  such  condition  he  applied  for 
relief  from  his  deformity. 

"  The  idea,"  says  the  gentleman  whose  practice  is  quoted,  "  of 
restoring  its  shape  by  what  is  known  as  '  contour-filling'  was 
abandoned  as  soon  as  thought  of,  as  was  also  that  of  the  usual 
method  of  pivoting,  for  the  following  reasons:  First,  we  would  be 
obliged  to  cut  away,  and  consequently  lose,  the  substantial  body  of 
the  tooth,  with  its  enamel  covering,  and  depend  upon  the  frailer  por- 
tion, the  root.  Secondly,  the  difficulty  of  matching  in  general  ap- 
pearance the  adjoining  teeth,  they  being  somewhat  peculiar.  And 
lastly,  the  knowledge  that  the  period  of  usefulness  of  pivoted  teeth 
is,  under  the  most  favorable  circumstances,  a  short  one.  So,  as 
neither  of  these  methods  afforded  the  two  important  desiderata  of 
permanency  and  natural  appearance,  I  decided  to  splice  the  broken 
tooth  with  a  piece  of  porcelain.  This  was  done,  and  the  contour 
perfectly  restored. 

"  The  method  of  proceeding  was  as  follows.  The  vitality  of  the 
tooth  had  been  destroyed  by  the  accident,  and  some  years  after  the 

30 


4^6  ORAL  DISEASES  AND   SUBGERY. 

pulp  canal  had  been  filled  with  gold.  The  fractured  portion  pre- 
sented an  uneven  edge  and  surface,  which  extended  diagonally  in- 
ward and  upward  toward  the  adjoining  central.  The  first  step  was 
to  remove  the  irregularities  and  obtain  a  perfect  edge  and  a  level 
surface,  by  means  of  a  flat  file.  I  then  drilled  up,  following  the  pulp 
canal,  to  the  depth  of  one-quarter  of  an  inch,  with  a  No.  16  drill  of 
Palmer's  set,  following  and  slightly  enlarging  with  a  flat  bur-drill. 
A  small  square  gold  box  was  next  constructed,  placed  in  the  canal, 
and  the  four  sides  carefully  and  firmly  filled  around  with  gold.  Into 
this  box  a  pin  made  of  platina  gold  fits  accurately,  the  pin  being 
split  fully  two-thirds  of  its  length.  At  this  point  an  impression  was 
obtained  of  the  broken  tooth  and  the  adjoining  central  and  lateral 
ones.  The  pin,  which  had  been  left  long  enough  to  project  three- 
sixteenths  of  an  inch  from  the  box,  indicated  in  the  impression  the 
inclination  of  the  canal. 

"A  cross-pin  plain  plate  tooth  was  next  selected  to  exactly  match 
in  color  the  natural  one ;  it  was  ground  away  equally  from  the  cut- 
ting edge  and  neck,  so  as  to  leave  the  pins  as  nearl}'  as  possible  in 
the  centre  of  the  porcelain  ;  it  was  then  fitted  accurately  to  the 
tooth,  and  the  cutting  edge  ground  to  imitate  that  of  the  adjoining 
central. 

"  The  piece  was  at  this  point  found  to  nearly  cover  the  mouth  of  the 
box,  being  almost  as  thick  as  the  tooth  itself.  This  difficulty  was 
readily  obviated  by  cutting  off  all  that  projected  of  the  gold  pivot 
and  upon  its  end  soldering  a  small  plate,  which  fitted  accurately 
upon  the  plane  mentioned  above  as  having  been  leveled  with  the 
file.  A  gold  backing  was  then  fastened  upon  the  piece,  and  a  slight 
concavity  ground  in  the  porcelain  to  receive  the  little  plate.  Before, 
however,  finally  soldering  the  piece  to  this  plate,  it  was  temporarily 
fastened  with  cement  and  tried  in  the  mouth,  as  the  plaster  cast  is 
liable  to  undergo  some  change  in  handling.  It  was  then  removed, 
after  some  little  extra  adjustment,  invested  iu  sand  and  plaster, 
and  the  backing  and  plate  united  by  solder. 

"  The  piece  can  be  removed  and  replaced  with  every  facility,  and 
the  flat  surface  cleansed  and  polished  whenever  deemed  necessary. 

"When  in  position,  the  line  of  union  is  almost  imperceptible,  and 
is  really  not  observed  unless  attention  is  specially  directed  to  it,  and 
a  very  close  examination  made. 

"  It  has  now  been  worn  and  thoroughly  tested  for  several  weeks, 
and  its  appearance  is  unchanged." 


ARTIFICIAL  DENTURES.  467 

AETIFICIAL  DENTURES— THE  IMPRESSION. 

Plate  Teeth. — The  proper  preparation  of  a  mouth  for  the  recep- 
tion of  a  plate  implies  that  the  operator  consider  in  the  relations  of 
each  case  the  hygienic,  mechanical,  and  artistic  considerations  there- 
with necessarily  associated:  one  mouth,  the  lips  being  long;  the 
process  full,  the  arch  markedly  concave,  and  of  some  depth  ;  the 
gums  solid  and  resisting ;  the  submucous  structure  neither  deficient 
nor  excessive  ;  the  teeth  all  absent,  or  such  as  may  remain  having 
harmonious  relation  ;  temperament  lymphatic  ;  such  a  mouth  the 
merest  tyro  will  accommodate.  On  the  contrary,  lips  short ;  process 
absorbed  to  a  line;  arch  flat;  gums  irregularly  flaccid  and  hard; 
teeth  all  gone,  or,  where  some  remain,  inharmonious  to  a  common 
articular  relation ;  temperament  nervous ;  such  a  mouth  the  most 
refined  skill  will  scarcely  serve  to  satisfy. 

A  mouth  before  prepared  to  receive  a  denture,  full  or  partial,  is  to 
be  free  from  all  roots  which  may  have  association  with  the  parts  to 
be  occupied  ;  teeth  irregular  to  the  arch,  and  thus  the  source  of  de- 
ficient symmetry,  or  such  as  may  interfere  with  a  successful  fitting  of 
the  artificial  piece,  or  such  as  may  be  diseased  and  lacking  in  promise, 
these  are  to  elicit  attention  and  judgment. 

As  a  rule,  a  plate  is  not  to  rest  upon  a  root,  healthy  or  unhealthy. 
The  retention  of  an  isolated  tooth  in  the  dental  arch  (all  the  others 
having  been  lost),  however  healthy  and  symmetrical,  except  it  be  in  a 
position  where  a  plate  is  not  to  go  back  of  it,  will  be  apt  to  antag- 
onize the  merits  of  any  denture,  however  perfect  its  construction. 
Soft  teeth  are  not  to  be  clasped.  A  cachectic  mucous  membrane  is 
to  be  covered  alone  with  a  gold  plate  which  has  been  alloyed  with 
platinum,  the  baser  materials  being  irritative.  A  turgid  congested 
membrane  is  not  capable  of  affording  an  impression  which  will  allow 
a  denture  to  be  useful.  Scorbutus,  ptyalism,  all  unhealthy  condi- 
tions are  to  be  corrected  before  an  impression  is  taken.  Clasp  teeth 
are  to  be  freed  from  tartar,  and  (except  when  the  denture  is  to  be 
temporary)  alveoli  are  to  be  absorbed. 

The  Impression. — The  first  step  in  the  construction  of  an  artificial 
denture  is  the  taking  of  an  impression,  or  measurement.  This  is  in 
the  province  of  the  surgeon,  and  consists  simply  in  filling  a  tray  (of 
which  every  size  and  variety  are  supplied  at  the  depots)  with  soft- 
ened wax,  plaster,  or  other  impression  material,  and  pressing  it  over 
the  parts  to  be  modeled. 


468 


ORAL  DISEASES  AND   SURGERY. 


Trays  are  of  two  general  forms,  the  one  being-  designed  for  the 
superior  arch,  the  other  for  the  inferior. 


Fig.  192. — Tray  for  Superior  Jaw.    Fig.  193. — Tray  for  Inferior  Jaw. 


In  selecting  a  tray  for  use  in  any  special  case,  regard  is  to  be 
had  to  the  requirements  of  the  case.  First,  such  a  tray  is  to  be 
employed  as  shall  admit  of  easy  passage  through  the  labial  commis- 
sure. If  an  arch  be  deep  in  its  palatine  aspect,  the  tray  used  will 
demand  to  have  marked  convexity,  or  otherwise  a  common  tray 
may  be  made  to  answer  equally  well  for  deep  or  shallow  arches  by 
having  a  false  bottom.  For  application  to  the  lower  arch,  a  deep 
or  narrow  rim  will  be  found  demanded,  as  the  process  may  be  promi- 
nent or  the  reverse.  In  many  mouths  the  site  of  the  original  alveo- 
lar process  will  be  found  to  have  entirely  disappeared,  leaving  a 
perfectly  flat  surface,  requiring  a  tray  without  the  slightest  flange. 

A  tray  is  to  be  large  enough  to  embrace  the  alveolar  arch,  leaving 
a  space  between  the  process  and  rim  of  about  a  quarter  of  an  inch  : 
it  is  to  be  deep  enough  to  include  the  tubers  of  the  upper  jaw,  or  to 
touch  the  rami  of  the  lower.  If  teeth  long  and  prominent  stand  in 
either  jaw,  particularly  the  anterior  of  the  lower,  as  is  very  com- 
mon, it  may  be  found  more  convenient  to  use  one  so  cut  as  to  admit 
of  such  teeth  passing  through  it.  (Fig.  194.)  This,  however,  is  not 
a  necessity,  and  not  always  even  a  convenience. 

Modifications  on  these  common  trays  ai'e  numerous;  few  practi- 
tioners, however,  recognize  sufficient  merit  in  them  to  feel  their  con- 
sequence, finding  rather  in  a  skill  the  result  of  practice  that  which 
meets  the  various  requirements.  One  of  the  very  best  impressions  I 
have  ever  seen  was  taken  with  a  piece  of  shingle,  whittled  for  the 


ARTIFICIAL  DENTURES. 


469 


occasion, — but  the  hand  that  secured  the  cast  was  skillful  and  experi- 
enced. I  have  never  in  my  own  practice  employed  other  than  the 
character  of  trays  here  shown,  and  take  it  for  granted  that  my  trouble 
in  getting  satisfactory  impressions  has  been  about  of  a  common  experi- 

PiG.  194.— Tray  for  Passage  of  Teeth. 


ence  with  others.  As  suggested,  however,  I  employ  for  the  palatine 
arch  the  tray  with  a  false  bottom.  Any  one  can  make  such  false 
bottoms  for  himself  by  replacing,  with  pieces  of  tin  or  other  metal 
bent  into  shape,  the  centre  which  is  to  be  cut  from  the  tray  as 
shown  in  Fig.  192.  Having  a  number  of  these  bottoms  (which 
should  be  somewhat  larger  than  the  piece  removed),  an  operator 
finds  himself  requiring  very  few  trays:  half  a  dozen,  or  certainly 
a  dozen,  will  be  sufficient. 


The  materials  used  for  taking  impressions  are  wax,  plaster  of 
Paris,  and  gutta-percha,  either  being  used  alone  or  in  combinations. 
The  inexperienced  should  begin  with  wax,  as  this  is  most  simple 
and  easy  of  manipulation,  and  at  the  same  time  quite  capable  of 
meeting  all  indications. 

Wax. — Two  kinds  of  wax  are  used,  the  white  and  the  yellow:  of 
these,  the  white  is,  on  some  accounts,  to  be  preferred.  It  will  take 
a  sharper  impression,  and  has  not  its  shape  so  readily  deranged. 
An  objection,  however,  is  its  want  of  plasticity  as  compared  with 
the  yellow,  much  more  time  and  trouble  being  required  to  prepare 
it  for  the  tray,  while  corresponding  increase  in  pressure  is  demanded 
to  force  it  into  place, — the  latter  being  a  matter  of  importance  where 
there  is  excess  of  the  submucous  cellular  tissue. 


470  ORAL  DISEASES  AND   SURGERY. 

Yellow  wax,  when  pure,  will,  under  all  ordinary  circumstances, 
afford  a  satisfactory  impression.  To  soften  it  to  a  required  consist- 
ency, which  should  be  about  that  of  dough,  it  is  only  necessary  to 
work  it  at  the  fire,  or  over  a  spirit-lamp.  Having  selected  a  tray 
and  observed  the  requirements  of  the  special  case,  that  is,  the  matter 
of  depth  of  mouth,  position  of  remaining  teeth,  and  character  of  mu- 
cous membrane,  whether  hard  or  soft,  yielding  or  unyielding,  the  wax 
is  piled  into  the  tray,  being  heaped  in  the  middle  if  the  mouth  is 
deep,  smoothed  and  flattened  if  shallow  ;  the  wax  to  be  very  soft  if  the 
membrane  be  flaccid,  of  greater  consistence  if  it  be  firm.  The  operator, 
if  to  take  an  impression  of  the  upper  jaw,  stands  behind,  leaning  over 
the  head  of  the  patient ;  if  of  the  lower,  a  position  is  assumed  in  front 
and  to  the  right.  The  tray  and  wax  being  in  the  mouth,  observa- 
tion is  demanded  to  see  if  such  correspondence  of  relation  exists  as 
will  allow  of  the  tray  being  carried  into  place.  If  care  be  not  exer- 
cised in  this  direction,  it  will  frequently  be  found  that  the  cup  is  not 
far  enough  in  the  mouth,  or  perhaps  is  too  far  in,  or  too  much  to 
one  or  the  other  of  the  sides,  so  that,  in  carrying  it  into  place,  the 
sharp  edge  of  some  portion  of  the  ridge  comes  down  upon  the  gum, 
producing  thus  not  only  much  pain,  but  rendering  the  impression 
good  for  nothing.  A  proper  correspondence  existing,  it  only  remains 
to  press  the  tray  gently  and  steadily  upon  the  arch,  throwing  the 
lip  off  should  it  interfere;  a  manipulation  easily  accompli.-5hed  by 
running  a  finger  between  the  lip  and  wax.  A  tray  is  never  to  be 
rocked  into  place,  but  rather  carried  with  all  steadiness  until  it  is 
felt  to  be  fixed  and  firm.  Such  a  bearing  obtained,  the  finger  of  the 
operator  is  to  press  the  wax  around  the  external  face  of  the  alveolar 
process,  and  where  the  false  bottom  has  been  used  this  is  to  be 
forced  into  the  roof  of  the  mouth.  If  the  impression  is  of  the  lower 
jaw,  then  it  is  to  be  pushed  with  the  finger  against  the  internal  face  of 
the  process  as  well  as  against  the  external.  Before  removing  an 
impression  of  wax  from  the  mouth,  it  should  be  allowed  to  remain 
a  few  minutes  to  harden.  If,  in  the  withdrawal,  suction  is  recog- 
nized, the  impression  will  almost  certainly  be  found  to  prove  a  good 
one.  A  tray  is  held  most  steadily  in  the  mouth  by  being  supported 
on  either  side. 

Some  operators,  skillful  in  the  use  of  wax  as  an  impression  mate- 
rial, find  it  necessary  to  employ  a  strand  of  silk  or  thread  run 
through  the  wax  just  before  introducing  it  into  the  mouth,  that  after 
securing  the  cast  they  may  get  it  away  by  letting  in  air  through  the 
withdrawal  of  the  string;  the  accuracy  of  the  fit  they  obtain  result- 


ARTIFICIAL  DENTURES.  471 

ing  in  a  suction  which  makes  it  otherwise  difficult  to  get  away  the 
tray  without  a  derangement  of  the  impression. 

Before  taking  an  impression,  a  mouth  is  to  be  cleared  of  saliva 
and  mucus.  This  is  most  conveniently  accomplished  through  rinsing 
with  water  and  cologne,  a  teaspoonful  of  the  latter  to  half  a  goblet 
of  the  former,  or,  if  more  convenient,  the  cologne  may  be  replaced 
with  alcohol. 

It  is  occasionally  found  recommended  that  immediately  upon  the 
withdrawal  of  a  wax  impression  from  the  mouth  it  be  plunged  into 
ice-water,  or  otherwise  that  it  be  laid  upon  ice.  This  is  a  practice 
scarcely  to  be  indorsed,  the  varying  thickness  of  the  wax  resulting 
in  unequal  contraction.  Unless  hurry  exists,  it  is  much  better  to 
leave  the  cast  to  the  existing  state  of  the  atmosphere. 

Sulphate  of  Lime — Plaster  of  Paris. — Plaster  of  Paris  mixed 
with  water  into  a  paste  is  very  widely  employed  as  an  agent  in  the 
taking  of  impressions.  Plaster  to  be  useful  for  such  purpose  must 
be  of  the  very  best  quality;  this  implies  that  it  has  been  well  cal- 
cined and  thoroughly  pulverized.  To  employ  it,  the  operator  selects 
a  tray,  and  filling  it  with  the  plaster,  which  has  been  semi-liquefied 
into  a  self-sustaining  paste  or  batter,  it  is  passed  into  the  mouth  in 
such  manner  that  bubbles  of  air  shall  not  be  caught  in  the  depth 
of  the  arch;  that  is,  the  pressure  which  carries  the  mass  into  place 
is  to  be  exerted  gradually  from  the  front  backward. 

For  plaster  (employing  it  with  the  upper  arch),  cups  or  trays,  as 
portrayed  in  Fig.  192,  are  commonly  used.  A  plan,  however,  ])re- 
ferred  by  many,  consists  in  first  taking  an  impression  in  wax,  pre- 
cisely as  has  been  directed.  This  secured,  the  surface  of  impression 
is  indifferently  cut  away,  simply  with  the  view  of  securing  what 
might  be  termed  a  fairly-fitting  wax  tray.  Into  this  is  now  poured 
the  plaster  batter,  and  the  whole  is  reintroduced  into  the  mouth. 

Employing  plaster  for  the  lower  arch,  the  tray  as  shown  in  Fig. 
193  is  found  entirely  applicable.  The  requisites  of  a  tray  holding  tlie 
plaster  batter  are,  depth  of  flange  sufficient  to  invest  the  alveolar 
face  to  an  extent  required  to  be  covered  by  the  paste,  and  that  re- 
lation of  arch  which  shall  insure  the  plaster  reaching  every  position 
of  tUe  part  to  be  modeled. 

To  take  an  impression  in  plaster,  a  patient  is  to  be  seated  upon  a 
low  chair,  and  the  head  is  to  be  inclined  forward  at  an  angle  sufficient 
to  prevent  the  falling  of  particles  of  the  batter  back  into  the  fauces. 
The  batter  is  to  be  of  that  consistency  which  neither  allows  it  to  run 


472  ORAL  DISEASES  AND  SURGERY. 

from  the  tray,  nor  on  the  other  hand  so  stiff  and  hard  that  it  may 
not  take  the  desired  impression.  The  time  required  for  setting  is 
about  three  minutes;  it  may  be  shorter  or  it  may  be  longer, — this 
depending  on  the  character  of  the  plaster  used.  The  proper  time 
for  the  removal  from  the  mouth  of  a  plaster  impression  is  designated 
by  the  sharp,  abrupt  break  to  be  seen  by  fracturing  any  inconsiderable 
and  unimportant  fragment,  or  by  testing  such  portion  as  may  be  left 
in  the  mixing  vessel.  The  matter  of  the  time  for  removal  is  of  very 
marked  importance ;  should  the  batter  not  have  set,  the  cast  is  of 
course  good  for  nothing.  Should  it,  on  the  contrary,  have  become 
too  solid,  it  might  bring  a  portion  of  the  mucous  membrane  with  it, 
particularly  in  the  case  of  the  superior  arch. 

Plaster  that  is  slow  in  setting  finds  the  defect  removed  by  the 
addition  of  a  small  portion  of  common  table  salt,  or,  what  is  thought 
by  some  to  be  better,  the  sulphate  of  potash. 

Plaster  of  Paris  as  an  agent  for  impressions  finds  its  most  conve- 
nient aj)plication  to  edentalous  arches ;  that  it  is  used,  however, 
with  all  success  for  partial  sets  of  teeth  is  daily  demonstrated.  To 
take  a  partial  impression  it  is  found  more  convenient  to  have  a  tray 
with  a  false  flange.  After  the  batter  has  set,  this  flange  is  to  be  with- 
drawn, the  bottom  part  of  the  tray  being  separated  from  the  mass 
by  means  of  the  point  of  the  knife-blade.  Next,  the  impression  is 
broken  into  pieces,  each  fragment  being  removed  and  preserved  with 
all  care.  When  all  are  away,  each  piece  is  coaptated  with  its 
fellow,  thus  restoring  the  cast. 

A  second  mode  of  taking  a  partial  impression  is  found  in  the  use 
of  the  wax  cast :  the  plai<ter  hardened,  the  heated  blade  of  a  knife 
separates  the  tray  and  wax  ;  the  cup  thus  detached,  the  wax  is 
quickly  and  easily  removed  from  the  plaster  ;  the  exposed  cast  is 
now  broken  and  treated  as  before  described. 

Occasionally,  indeed  frequently,  will  it  happen,  that  if  the  proper 
moment  be  secured,  a  plaster  cast,  even  although  it  inclose  several 
teeth,  may  be  removed  with  reasonable  facility  without  occasion  for 
the  fracturing  as  suggested.  It  is  a  point  with  man}^  operators  to 
try  and  save  themselves  this  trouble,  and  with  a  reasonable  experi- 
ence it  is  oftentimes  to  be  avoided. 

Gutta-Percha. — This  material,  used  alone,  has  never  impressed 
the  author  as  an  agent  of  sufificient  merit. to  warrant,  in  this  direc- 
tion, any  special  commendation.  It  is  not  only  troublesome  to 
manipulate,  but  from   its  tendency  to  undue  contraction,  as  influ- 


ARTIFICIAL   DENTURES.  473 

enced  by  circumstances,  is  tedious  to  look  after;  it  may  not  have 
comparison  either  with  the  wax  or  plaster.  As  an  agent  of  admix- 
ture with  wax,  however,  it  is  at  times  found  a  most  satisfactory 
adjunct,  insuring,  as  it  does,  an  accuracy  and  sharpness  in  outline 
which  is  the  highest  recommendation  of  an  impression.  Gutta- 
percha alone,  or  in  combination  with  wax,  is  used  precisely  the 
same  as  the  pure  wax,  being  softened  by  moist  or  dry  heat,  placed 
in  the  cup,  and  thus  applied.  When  the  gutta-percha  alone  is  used, 
trouble  may  be  experienced  in  getting  it  from  the  mouth,  particu- 
larly in  cases  where  teeth  stand  in  an  irregular  relation  to  one 
another  in  the  arch. 

The  Model. — An  impression  of  the  mouth  secured,  the  duty  of 
the  surgeon  may  be  for  the  time  ended  in  passing  the  .tray  to  the 
mechanical  dentist;  or,  if  the  interest  of  the  matter  invite  him,  he 
may  pass  to  the  succeeding  step  of  making  a  model.  This  model 
is  to  be  a  fac-siraile  of  the  parts  taken  in  the  impression,  and  is 
made  in  a  verj'^  few  moments,  as  follows.  If  the  impression  be  of 
wax,  or  gutta-percha,  or  of  the  mixture  of  wax  and  gutta-percha, 
the  surface  is  to  be  thoroughly  smeared  with  oil.  Placing  the  tray 
now  upon  a  table,  a  strip  of  paper,  or  lead,  or  waxed  cloth, — any 
convenient  thing,  being  of  a  length  sufficient  to  encircle  the  circum- 
ference of  the  impression,  and  of  a  width  not  less  than  one  and  a 
half  inches, — is  to  be  placed  around  the  tray,  forming  thus  a  tem- 
porary cup,  the  bottom  of  which  is  the  impression.  Taking  now 
plaster  of  Paris  sufficient  in  quantity  to  fill  this  cup,  it  is  mixed  with 
water  into  a  batter  of  the  consistency  of  cream,  and  in  this  state 
poured,  with  care,  beginning  at  one  corner,  into  the  cup.  When 
set  solid,  which  will  require  two  or  three  hours,  the  strip  is  to  be 
lifted  away,  the  tray  removed  by  healing  it  slightly,  and  the  wax, 
being  warmed  and  softened,  is  picked  away  little  by  little  by  any 
convenient  instrument,  an  ordinary  pocket-knife  answering  the  pur- 
pose quite  as  well  as  anything  else.  This  model  is  the  cast  to  which 
the  mechanician  works  ;  it  is  a  perfect  likeness  of  the  mouth  to  which 
the  teeth  are  to  be  fitted. 

In  the  case  of  the  plaster  impression  the  manipulations  for  se- 
curing the  model  differ  somewhat  from  the  above.  The  impression  is 
to  be  thinly  varnished,  when  dry  is  to  be  oiled,  and  the  cream  batter 
poured  as  before.  When  solid,  the  plaster  impression  is  to  be 
broken  by  the  taps  of  a  mallet,  and  thus  in  pieces  lifted  away. 

A  succeeding  step  is  the  preparation  of  a  plate  to  cover  and  fit 


474  ORAL  DISEASES  AND   SURGERY. 

accurately  the  arch, — a  plate  of  gold,  platinum,  or  silver.  We  will 
not  consider  what  is  known  as  the  vulcanite  base,  as  it  may  not  be 
accepted  as  a  desirable  material  to  be  used  in  such  relation. 

The  preparation  of  the  plate  is  the  first  relation  of  the  surgeon 
with  the  mechanical  dentist.  The  model  being  transferred,  such 
plate  may  be  quickly  returned,  ready  to  be  tried  in  the  mouth,  the 
artist  trimming  and  preparing  the  model  to  suit  the  requirements  of 
his  art. 

A  matter,  however,  associating  with  the  transfer  of  the  model,  is 
the  character  of  plate  required.  Dental  plates  are  of  two  kinds, — 
those  supported  by  clasps  or  bands  which  are  to  pass  about  certain 
teeth,  and  those  which  depend  on  atmospheric  pressure  for  support. 
Whether  the  one  or  other  of  these  means  may  be  employed  depends 
entirely  on  the  state  of  the  mouth.  When  all  the  teeth  are  gone, 
there  is,  of  course,  but  the  single  resource,  the  plate  must  be  made 
to  cover  the  full  arch;  and,  if  the  case  is  for  the  superior  jaw,  a 
cavity,  occupying  the  centre  of  the  palatine  face,  is  to  be  made 
in  the  plate.  Where  certain  teeth  are  present,  these  being  of  good 
shape  to  support  bands,  and  of  vigorous  health  and  solid  structure, 
it  may  be  a  matter  of  greater  comfort  to  the  patient  to  take  advan- 
tage of  such  means  to  give  him  a  plate  which  shall  allow  exposure 
to  a  greater  surface  of  mticous  membrane, — a  matter  of  little  conse- 
quence to  the  comfort  of  the  lymphatic  temperament,  but  of  much 
concern  to  the  nervous. 

The  plate  made,  the  next  duty  of  the  surgeon  consists  in  securing 
what  is  called  an  articulation.  This  considers  the  bite,  or  the  re 
lations  of  the  artificial  to  the  natural  teeth.  To  secure  an  articula- 
tion which  shall  afiford  all  requisite  information  to  the  mechanical 
dentist,  it  is  necessary  to  proceed  as  follows  : 

1.  The  Partial  Dentm'e. — Taking,  as  the  most  simple  illustration, 
a  plate  upon  which  is  to  be  placed  a  partial  denture,  say  the  six 
central  teeth  of  the  upper  jaw.  Try  the  plate  in  its  place,  and  see 
if  a  fit  has  been  secured  ;  fit  is  adaptability.  Every  part  of  a  plate 
should  rest  evenly  and  solidly  upon  its  base.  If  bands  have  been 
used,  these  are  to  inclose  the  special  teeth  to  which  they  are  related 
with  the  nicest  accuracy, — they  are  to  hug  the  teeth.  Where 
atmospheric  pressure  is  the  means  of  support,  the  relation  of  parts 
must  be  so  intimate  that  withdrawal  of  air  from  beneath  the  plate — 
effected  through  suction  by  the  tongue — causes  it  to  adhere  to  the 
parts  with  more  or  less  tenacity. 

Satisfied  of  the  adaptability  of  the  plate,  a  succeeding  step  con- 


ARTIFICIAL  DENTURES.  475 

sists  in  softening  a  piece  of  beeswax  precisely  as  was  done  for  the 
wax  impression,  and,  moulding  this  on  that  part  of  the  plate  to  be 
occupied  by  the  new  teeth,  the  patient  is  directed  to  close  his  mouth. 
This,  as  is  seen,  bites  the  lower  teeth  into  the  wax,  thus  affording 
knowledge  of  how  the  artificial  teeth  are  to  be  set.  Associated 
with  this  step  is  the  trimming  of  the  wax  as  to  what  shall  seem  the 
required  length  of  the  new  teeth  ;  also  the  wax  overlying  that 
portion  of  the  plate  which  covers  the  external  face  of  the  alveolar 
ridge  may  be  so  trimmed  and  moulded  as  to  give  proper  support  to 
the  overlying  lip.  In  such  partial  cases,  however,  it  is  not  at  all  a 
necessit}^  that  anything  more  be  done  by  the  surgeon  than  secure 
the  bite  as  directed.  The  mechanician,  if  at  all  an  artist,  has  every 
required  guide  in  the  surrounding  relations.  The  trimming  and 
modeling  he  can  do  to  suit  himself.  A  shade,  however,  is  required 
by  him  ;  this  is  secured  by  matching  in  color  the  natural  by  an 
artificial  tooth,  of  which  latter  the  surgeon  is  to  have  at  his  com- 
mand quite  a  number. 

2.  The  Fall  Half-Denlure. — A  full  half-denture  implies  the  set 
complete  either  of  the  upper  or  the  lower  arch.  We  consider  first  the 
upper.  Try  the  plate  in  the  mouth  to  test  its  adaptability.  If  this 
is  satisfactory,  let  the  patient  close  upon  it  the  teeth  of  the  lower 
jaw.  This  affords  information  as  to  a  general  line  at  which  these 
teeth  will  strike  the  plate.  Take  now  the  plate  from  the  mouth, 
and  build  upon  it  a  rim  of  wax  of  a  height  which,  when  in  the 
mouth,  will  represent  the  required  length  of  the  new  teeth.  Such 
height  is  readily  distinguished  by  trimming  the  wax  little  by  little, 
until,  in  the  various  movements  of  the  lips,  as  in  talking,  laughing, 
etc.,  it  is  seen  to  afford  the  promise  of  a  natural  expression.  This 
secured,  let  the  patient  make  a  line  of  the  impression  of  his  lower 
teeth  by  slightly  biting  into  the  wax.  Next  the  support  of  the  lip 
is  to  have  consideration.  This  pertains  of  course  to  the  guQi  portion 
of  the  teeth.  To  afford  here  the  requisite  information  to  the  artist, 
it  is  onl}^  necessary  to  model  the  wax  until  the  external  parts  are 
seen  to  have  their  proper  position.  This  is  done  by  building  upon 
the  flange  of  the  plate  a  rim  of  wax  of  such  form  and  shape  as  are 
proved  to  be  right  by  the  impression  produced  on  the  contour  of  the 
lip.  Accompanied  by  its  shade  tooth,  the  articulation  is  now  ready 
to  be  again  transferred. 

3.  An  articulation  of  the  full  lower  denture  is  to  be  secured  in  a 
manner  precisely  similar  to  that  practiced  with  the  superior. 

4.  The  Articulation  of  a  Complete  Denture. — A  complete  denture 


476  ORAL  DISEASES  AND  SURGERY. 

implies  a  set  of  teetli  full  above  and  below.  Having  the  plates,  the 
surgeon  first  places  them,  each  in  its  proper  place,  and  causes  the 
patient  to  close  the  mouth  that  thereby  some  general  conception  of  the 
relation  of  the  parts  may  be  obtained.  Measuring  now  the  length  of 
the  lips  that  an  idea  may  be  afforded  of  the  required  length  of  the  new 
teeth,  rims  of  wax  are  to  be  built  upon  the  two  plates  precisely  as 
before  directed.  This  accomplished,  each  plate  is  to  be  placed  in 
position,  and  the  relations  studied ;  the  lip  is  to  be  properly  sup- 
ported, the  wax  is  to  represent  the  proper  length  of  the  new  teeth, 
and  the  arches  are  to  have  such  relation  with  each  other  that  it 
is  seen  that  the  tongue  is  accommodated  with  the  room  required 
for  its  untrammeled  movements:  likewise  is  it  to  be  observed  that 
the  line  at  which  the  rim  of  wax  rests  upon  each  plate  is  calculated 
to  throw  the  centre  of  gravity  of  the  new  teeth  on  a  bearing  which 
antagonizes  any  tendency  in  the  plate  to  tilt.  This  latter  matter, 
however,  the  mechanical  dentist  should  himself  know  all  about;  it 
is  not  a  necessity  that  the  surgeon  particularly  heed  it.  Finally,  the 
plates,  with  their  rims,  having  been  accommodated,  each  to  its  special 
requirements,  the  two  are  put  at  the  same  time  in  place  in  the  mouth. 
This  done,  the  patient  is  directed  to  close  naturally  the  jaws ;  as 
now  the  rims  of  wax  meet,  and  adhere  to  each  other,  the  natural 
bite  or  articulation  is  secured.  The  operator  now,  with  a  knife, 
or  other  convenient  instrument,  marks  from  plate  to  plate  upon  the 
united  rims  of  wax,  a  mark  which  represents  the  exact  centre 
of  the  mouth,  and  besides  this  central  mark  two  others,  one  upon 
either  side.  The  plates  may  now,  in  their  united  condition,  be  re- 
moved from  the  mouth,  and  are  ready  for  another  transfer.  If,  how- 
ever, it  happens,  as  indeed  is  not  unlikely,  that  in  removing  the 
plates  they  have  separated,  it  makes  but  little  difiference,  as  by  the 
lines  which  have  been  made  they  may  at  any  moment  be  replaced 
in  the  original  relation. 

Peculiarities  in  articular  relations  occasionally  present,  the  man- 
agement of  which  requires  experience  to  make  easy.  As  an  ex- 
ample, reference  may  be  made  to  a  condition  in  which  teeth 
remaining  in  both  the  upper  and  lower  arches  hold  such  mutual 
relation  that  in  the  closure  of  the  mouth  they  pass  each  other, 
allowing  thus  the  teeth  of  either  jaw  to  strike  the  gum  of  its  antago- 
nist. Proper  articular  relation  here  resides  in  so  arranging  the 
artificial  teeth  that  the  bite  is  restored  to  the  original  plane.  In 
other  words,  in  the  arrangement  of  the  wax,  the  closure  of  the  jaw 
is  to  show  the  impression  upon  the  wax  on  that  plane  which  would 


I 


ARTIFICIAL   DENTURES.  477 

be  natural,  should  the  irregularly  placed   teeth  strike    instead   of 
passing  each  other. 

In  an  attempt  to  procure  almost  any  but  the  most  simple  of  ar- 
ticulations, the  operator  finds  himself  annoyed  by  false  bites,  the 
patient  closing  his  mouth  in  every  way  but  that  which  is  the  right 
one ;  and  most  particularly  has  experience  shown  this  to  be  a  result 
where  special  pains  are  taken  to  instruct  a  patient  as  to  the 
manner  of  the  closure.  A  proper  bite,  it  is  to  be  recognized,  is  the 
natural  one.  After  arranging  the  wax,  tell  the  patient  to  close  the 
mouth.  Having  thus  obtained  an  articulation,  take  the  piece  out,  and 
after  a  few  minutes  replace  it ;  procuring  now  a  second  bite,  should 
both  correspond,  the  inference  may  be  in  favor  of  correctness. 
Should,  however,  a  different  impression  be  made  upon  the  wax,  one 
or  the  other  of  the  bites  is  necessarily  wrong,  and  the  test  is  to  be 
repeated  until  satisfaction  is  secured. 

Articulating  a  Denture. — When  an  articulation,  or  bite,  as 
just  described,  is  faultless,  the  relations  of  an  artificial  denture 
should  be  equally  perfect.  It  very  frequently  happens,  however, 
that,  from  fault  either  in  the  surgeon  or  the  artist,  the  desired 
and  absolutely  necessary  perfectness  of  occlusion  does  not  exist, 
certain  teeth  being  seen  to  strike  unduly,  thus  denying  a  common 
occlusion  ;  or  it  may  be  that  the  cusps  are  found  wrongly  placed 
as  regard  is  had  to  their  articulating  neighbors. 

To  appreciate  the  character  of  a  proper  articulation,  the  reader 
will  refer  to  Fig.  1,  also  to  description,  page  109. 

Integrity  and  mechanical  adaptability  in  articulation  are  essentials 
to  usefulness  and  comfort.  Artificial  teeth  which  do  not  strike 
properly  can  never  be  of  service  or  good  to  the  wearer.  When, 
therefore,  a  finished  set  of  teeth  are  found  in  this  direction  to  be 
so  far  out  of  the  way  as  not  to  permit  of  satisfactory  correction,  the 
very  best  thing  is  to  begin  again,  and  have  them  made  over.  Such 
a  necessity  must  come  more  or  less  frequently  to  the  inexperienced  ; 
each  mistake,  however,  has  in  it  the  compensation  of  a  lesson  more 
instructive  than  a  dozen  successes. 

Artificial  dentures  slightly  false  in  articulation  constitute  the 
rule  rather  than  the  exception.  Relief  here  is  found  in  recognizing 
the  false  touching  points,  and  by  the  u.se  of  the  corundum  stick,  or 
preferably  the  lathe  (see  Fig.  191),  cutting  them  away. 

Closing  his  own  teeth,  one  recognizes  a  solidity  and  regularity  of 
occlusion.  This  is  the  whole  secret  of  articulation.  No  tooth  is  to 
touch  before  its  fellow :  the  bite  is  to  be  common. 


CHAPTER    XXL 


IRREGULARITIES   OP   THE    TEETH. 


Teeth  irregularly  related  to  the  common  arch  are,  under  favor- 
able conditions,  capable  of  having  the  malposition  corrected  without 
ill  results. 

Conditions  to  be  appreciated  are:  1st,  general  and  local  health; 
2d,  age  of  patient;  3d,  nature  of  alveolar  process. 

A  patient  laboring  under  dyscrasia,  or  one  of  extreme  nervous 
temperament,  will  scarcely  be  found  a  proper  subject  for  the  endur- 
ance of  details  necessary  for  the  correction  of  misplaced  teeth :  the 
first,  by  reason  of  a  degenerating  inflammatory  action  almost  certain 
to  be  provoked  ;  the  second,  because  of  nervous  excitability  aroused, 
which  involves  a  risk  to  the  health  at  large,  of  greater  import  than 
any  local  good  which  may  result. 

A  patient  over  twenty-five  years  of  age  may,  as  a  rule,  be  deemed 
to  have  attained  to  a  solidity  and  fixedness  of  stature  which  render 
the  risk  of  change  overbalancing  the  promise  of  good.  The  period 
intervening  between  twelve  and  seventeen  years  of  age  is  found  by 
experience  to  be  the  time  of  election  for  this  class  of  operations. 

An  alveolar  process  of  loose  structure  is  more  capable  of  affording 
response  to  a  mechanical  impression  than  is  one  of  solid  character. 
In  the  first,  a  tooth  may  be  quickly  changed  in  its  position  ;  in  the 
second,  not  only  is  more  time  required,  but  great  increase  in  the 
moving  force. 

Treatment  which  pertains  to  regularity  and  harmony  in  the 
second  denture  commences  with  the  first,  the  rule  being  that  a 
deciduous  tooth  is  not  to  be  extracted,  save  by  compulsion,  until  a 
successor  is  ready  to  take  its  place.     (See  Anomalies  of  Dentition.) 

A  tooth  is  changed  in  its  position  by  the  application  of  force 
drawing  in  the  required  direction.  The  physiological  changes  in- 
duced in  the  enveloping  process  are,  first,  absorption  of  the  parietes 
of  that  aspect  of  an  alveolus  pressed  upon  ;  second,  the  exudation  and 
organization  of  plasma  in  the  part  relieved.  Change  too  rapidly 
(478) 


I 


IRREGULARITIES  OF  THE   TEETH.  479 

effected  excites  iuflammation,  or  otherwise  draws  the  tooth  from  its 
cavity  ;  haste  in  the  correction  of  an  irregularity  is  never  safe. 

In  orthodontia,  as  in  every  other  department  of  surgery,  familiarity 
simplifies  practice.  To  move  teeth,  but  few  means  are  really  requi- 
site. Complexities  in  appliances  are  commonly  found  to  signify  lack 
of  true  skill. 

A  full  consideration  of  the  associations  of  a  case  is  to  precede 
operation  upon  it.  Such  consideration  embraces,  first,  age.  Asa 
rule,  it  will  not  be  found  good  practice  to  attempt  the  moving  of  an 
undeveloped  tooth,  the  parts  being  too  susceptible  and  irritable. 
(See  Dentition.)  Second,  condition.  Not  only  are  the  dyscrasic 
and  nervous  conditions  adverse  to  operation,  but  more  immediate 
expressions  are  also  to  be  taken  into  account.  Teeth,  from  the 
shape  and  direction  of  their  crowns,  are  sometimes  to  be  recog- 
nized as  possessed  of  peculiarities  of  fangs,  which,  in  a  proposed 
change,  must  compel  the  piercing  of  the  alveoli.  Again,  teeth  of 
bulky  crown  ma}'  have  stumpy  roots  of  such  limited  relation  to 
their  alveoli  that  very  slight  traction  will  drag  them  from  their 
sockets.  A  tooth  out  of  the  arch  may  be  a  supernumerary  ;  or  it 
may  in  every  respect  simulate  the  true  teeth  and  yet  not  belong  to 
the  regular  denture. 

The  inferior  anterior  teeth  of  the  second  set  are  in  nearly  all  in- 
stances found  more  or  less  irregular  in  the  manner  of  their  eruption, 
if  not  unduly  crowded  from  narrowness  of  the  arch  ;  it  will  be  the 
exception,  however,  where  they  will  not  prove  self-correcting.  Also 
is  it  found  the  case  that  in  nearly  every  instance  where  accommo- 
dating space  exists,  irregularly  developing  teeth,  wherever  situated, 
will  of  themselves  seek  proper  relation.  Early  interference  is  there- 
fore, because  of  such  natural  tendency  to  self-correction,  to  be 
deprecated,  except  where  it  is  evident  that  mechanical  relations 
render  such  self-correction  impossible.  A  single  example  may  illus- 
trate. Let  a  case  be  supposed  where  the  superior  central  incisors 
develop  with  their  cutting  faces  so  inclining  inward,  that  in  occlu- 
sion of  the  jaws  the  inferior  teeth  close  against  the  labial  surfaces  : 
here  it  must  be  seen  that  time,  instead  of  serving  to  correct  the  de- 
formity, will  only  increase  it.  In  such  an  instance,  a  correction 
as  immediate  as  possible  is  desirable.  Judgment  must  direct  the 
means  and  the  manner:  the  superior  teeth  should  certainly  be  placed 
outside  of  the  inferior:  if  it  is  done  without  provoking  inflammator}'- 
resistance,  however  accomplished,  the  means  employed  have  neces- 
sarily been  judicious.  (See  illustrative  cases.) 


480  ORAL   DISEASES  AND  SURGERY. 

Instances,  again,  are  met  with  where  certain  teeth  have  com- 
pletely changed  position:  a  lateral  incisor  appearing  in  the  situa- 
tion of  the  central,  the  central  occupying  the  place  of  the  lateral. 
Here  there  is  no  correction  possible,  except  it  be  found  in  extraction 
of  the  teeth  and  their  rearrangement  upon  a  plate,  or  through  the 
pivoting  process. 

Teeth  irregular  to  the  arch,  and  held  in  the  false  position  only 
by  pressure  from  the  articulating  teeth,  find  easy  correction;  forced 
into  proper  place,  the  same  teeth  which  continued  the  deformity 
will  prove  the  instruments  of  permanency  to  the  new  relation. 

The  apparatuses  used  for  correcting  irregularities  are  to  be  as 
delicate  as  regard  to  a  necessary  strength  will  allow  :  they  are  to 
permit  of  ready  change  of  form  or  relation  to  suit  the  constantly  vary- 
ing requirements  of  cases  ;  the  construction  and  application  should 
be  as  simple  as  practicable,  that  thus,  as  much  as  possible,  the 
assistance  of  the  patient  be  engaged  ;  they  are  to.be  easy  of  removal 
and  replacement,  that  thus  a  necessary  cleanliness  be  secured. 

In  the  relation  of  plates  to  the  necks  of  the  teeth,  care  is  to  be 
exercised  that  unduly  sharp  edges  shall  not  cut  the  enamel ;  while 
in  the  employment  of  gum  rings,  now  in  most  common  use,  atten- 
tion is  demanded  to  the  avoidance  of  injury  to  the  gums  so  apt  to 
ensue  from  the  sliding  up  of  the  ligature,  a  result  easily  avoided  by 
placing  between  the  gum  and  ring  a  thread  of  waxed  silk  tightly 
tied  around  the  tooth. 

Teeth  changed,  through  mechanical  means,  in  position,  are  to 
have  support  in  the  new  location  until  the  required  alteration  is 
effected  in  their  alveoli.  This  support  is  most  commonly  seen  to 
be  given  by  nature  :  as  for  example,  where  a  tooth  being  inside  of 
the  arch  and  so  retained  by  the  overlying  teeth,  being  forced  out- 
side, is  equally  compelled  to  retain  the  new  place  by  the  pressure  of 
the  very  same  teeth.  In  all  cases,  however,  where  circumstances 
deny  natural  support,  advantage  is  to  be  taken  of  mechanical  ap- 
pliances ;  such  appliances  being  found  in  ligatures,  metal  bands,  or 
plates. 

With  such  appreciation  of  the  simplicity  of  the  principles  under- 
lying the  practice  of  orthodontia,  a  few  illustrative  cases  in  prac- 
tice may  be  presented  as  hints  to  the  ingenuity  of  the  practitioner. 

Illustrative  Cases. — Fig.  195  exhibits  a  cast  taken  from  the 
living  mouth,  in  which,  as  is  seen,  the  bicuspidati  and  lateral  incisors 
approximate.     Age  of  patient,  ten  years. 


IRREGULARITIES   OF  THE   TEETH. 


481 


Studying  this  case,  it  becomes  recognized  that  a  required  space  is 
absent,  namely,  that  for  the  accommodation  of  the  cuspis  of  either 
side.  At  eight  years  of  age,  the  incisor  found  its  place  ;  at  nine  years, 
the  bicuspis.  Most  important  was  it  that  the  space  occupied  by  the 
deciduous  cuspis  should  be  preserved  by  the  retention  of  that  tooth 
until  the  eleventh  year,  the  period  of  eruption  for  the  permanent. 
Not  preserved,  the  room  naturally  became  occupied  by  adjacent 
teeth  ;  hence  irregularity  was  inevitable  :  unless,  indeed,  it  should 
have  happened  th.at  the  second  cuspis  remained  unerupted, — a  matter 
which  must  always  necessarily  occasion  more  concern  than  even  a 


Fig.  195. 


Fig.  196. 


deformity.  Fig.  196  exhibits  a  front  view  of  a  similar  mouth,  the 
cast  being  taken  in  the  fifteenth  year,  four  years  after  the  eruption 
of  the  cuspidati.  This  irregularity  is  the  one  most  frequently  to  be 
met  with. 

Treatment. — If  an  arch  so  presenting  exhibits  a  proper  articula- 
tion,— that  is,  if  the  bite  is  as  described  on  page  109, — then  a  practice 
lies  between  the  removal  of  the  projecting  cuspidati,  and  that  of  the 
immediately  adjoining  bicuspidati. 

As  facial  expression  is  concerned,  it  is  to  be  remembered  that 
much  of  character  resides  in  the  eye  teeth.  Many  mouths  from 
which  these  teeth  have  been  removed  possess  a  flat,  expressionless 
appearance,  most  undesirable.  Again,  it  is  found  that  these  teeth 
serve  as  keystones  to  the  arch  :  hence  it  frequently  follows  that 
secondary  irregularity  associates  with  their  removal. 

Where  a  mouth  with  overriding  eye  teeth  possesses  proper  articula- 
tion,— that  is,  where  the  superior  incisors  fully  override  the  inferior; 
where  the  bicuspidati  resemble  in  their  labial  outlines  the  cuspidati, 
and  where  the  approximation  of  these  teeth  with  the  lateral  incisors 
is  complete  and  regular ;  where  the  cuspidati  are  situated  well  for- 
ward, and  not  over  the  bicuspidati,  or  even  over  the  interspaces ; 
where  the  patient  is  advanced  in  years,  the  process  having  become 
fixed  in  its  relations:  it  is,  in  a  case  of  this  kind,  the  proper  practice 

31 


482  ORAL  DISEASES  AND   SURGERY. 

to  extract  the  eye  teeth.  On  the  contrary,  where  the  patient  is 
young,  where  the  articulation  is  harmonious,  where  the  projecting 
teeth  are  situated  over  the  interspace,  or,  still  better,  posterior  to 
it ;  where  the  bicuspidati  do  not  siniulate  in  appearance  the  cuspidati : 
the  practice  proper  to  be  pursued  consists  in  removing  the  under- 
lying premolars.  Here,  however,  arises  a  question.  The  anterior  or 
six-year  molars,  of  all  teeth  in  the  mouth,  excepting  perhaps  the 
dentes  sapientiae,  are  the  most  frequently  found  decayed.  If  these 
teeth  are  seen  to  be  carious  beyond  the  ability  of  cure,  and  if  the 
first  or  underlying  bicuspidati  are  sound  and  healthy,  will  not  expe- 
rience indorse  the  saving  of  these  latter  teeth  and  the  extraction  of 
the  diseased  organs? 

Experience  exhibits  that  the  developing  tendency  of  the  teeth  is 
always  in  a  forward  direction  ;  the  extraction  of  a  first  molar  does 
not  favor  to  any  extent  the  accommodation  of  the  cuspis:  the  second 
bicuspis  will  not  fall  back  into  the  space  made.  On  the  contrary,  a 
second  irregularity  is  favored  in  the  immediately  manifested  inclina- 
tion of  the  second  molar  to  fall  obliquely  forward,  thus  breaking  the 
harmony  of  the  grinding  relations. 

The  preservation  of  the  first  molar  teeth  is  of  great  importance  to 
the  usefulness  of  a  denture.  It  is  a  great  misfortune  where  they  have 
been  neglected.* 

A  third  condition  of  this  special  deformity  is  met  with  where  it 
is  evident  that  the  slightest  curtailment  of  the  arch  would  destroy 
the  harmony  in  articulation, — that  is,  the  overriding  is  so  slight  that 
the  extraction  of  two  teeth  might  possibly  result  in  the  anterior 
teeth  closing  directly  upon  each  other,  or  perhaps,  indeed,  in  the 
inferior  teeth  closing  outside.  Two  lines  of  practice  here  present. 
The  bicuspidati  may  be  removed  as  before  directed,  and  by  the  em- 
ployment of  an  occipito-mental  elastic  sling,  exhibited  and  described 
on  a  succeeding  page,  the  inferior  arch  may  be  retracted  ;  or  the 
superior  arch  may  be  enlarged  to  an  extent  which  shall  afford  the 
required  space  through  the  aid  of  instrumental  assistance  ;  or,  still 
again,  equality  may  be  maintained  by  the  extraction  of  correspond- 
ing bicuspidati  from  the  lower  jaw. 

*  The  inferiority  of  the  first  molars  is  fully  recognized.  Mr.  Tomes  sug- 
gests the  removal  of  these  teeth  under  the  circumstances  we  consider,  founding 
his  practice  on  the  following  statistics:  "Under  the  age  of  fifteen  the  re- 
spective liability  to  loss  from  caries  runs  in  the  following  order :  central 
incisors,  2  per  cent.  ;  lateral  incisors,  3i  per  cent. ;  canines,  2J  per  cent.  ;  first 
bicuspids,  7  per  cent. ;  second  bicuspids,  8J  per  cent.  ;  first  permanent  molars, 
683f  per  cent." 


IRREGULARITIES   OF  THE   TEETH. 


483 


Of  appliances  used  in  the  correction  of  irregularities,  every  variety 
is  to  be  found.  The  operator  will  always,  however,  find  himself 
best  served  in  employing  the  most  simple  means  capable  of  meeting 
indications. 


Fig.  197  represents  an  appliance  devised  by  Dr.  J.  D.  White,  the 
office  of  its  mechanism  being  the  enlargement  of  the  whole  superior 
arch  and  the  consequent  accommodation  of  any  outlying  tooth  or 
teeth.  Taking  an  impression  of  an  arch,  a  plate,  in  shape  as  shown, 
A,  is  made;  this  plate,  separated  into  two  parts,  has  its  association 
preserved  by  a  spiral  spring,  C,  so  arranged  as  to  lie  directly  back 
of  the  teeth,  being  thus  as  much  out  of  the  way  as  possible.  B 
represents  crib  bands  for  attachment  to  the  first  or  second  molar 
teeth,  as  may  seem  advisable.  D,  a  hinge,  joins  the  parts  in  front ; 
a  device,  however,  which,  for  the  purpose  now  considered,  is  to  be 
replaced  with  advantage  by  any  arrangement  admitting  of  lateral 
separation  on  the  line  of  division.  It  is  to  be  recognized  that  in  the 
tendency  of  the  spring  to  straighten  itself  the  plate  is  separated, 
outward  pressure  being  thus  exerted  against  each  tooth. 

A  second  appliance,  having  similar  import,  shown  in  Fig.  198,  is 
the  device  of  Dr.  A.  Westcott.  This 
apparatus,  as  must  be  appreciated, 
possesses  in  its  construction  the 
ability  to  move  outwardly  any  tooth 
or  teeth  requiring  change  of  posi- 
tion. The  instrument  may  thus  be 
described  :  First,  a  double  clasp 
(A,  A),  these  clasps  connected  to- 
gether by  a  straight  bar  made  of 
tubular  wire.  This  tube  has  a  screw  cut  in  its  inside  the  whole  length, 


484  OBAL  DISEASES  AND  SURGERY. 

and  is  soldered  to  one  pair  of  the  double  clasps  ;  the  other  pair  of 
clasps  are  soldered  to  a  wire  which  screws  into  the  tube,  the  object 
being  to  lengthen  or  shorten  the  bar  at  pleasure.  Next  a  flat  piece 
(C,  C)  of  sufficient  width  for  hinge-joints  is  soldered  to  the  bar.  To 
these  are  connected  by  hinge-joints  (F,  F,  F,  F)  a  series  of  tubes 
(D,  D,  D,  D),  each  having  a  screw  cut  on  the  inside,  these  receiving 
and  accommodating  an  equal  number  of  spurs  (C,  C,  C,  C).  These 
spurs,  as  is  recognized,  screw  back  and  forth  as  may  be  desired,  and 
are  therefore  capable  of  pushing  (in  time)  any  tooth  from  its  socket. 

Such  an  apparatus  prepared,  the  clasps  are  slipped  about  the  teeth 
for  which  they  have  been  adapted,  and,  slight  depressions  being 
reamed  upon  the  posterior  faces  of  such  teeth  as  it  is  designed  to 
move,  the  spurs  are  screwed  forward,  the  point  of  each  thrusting 
upon  the  depression  prepared  for  it. 

Examining  the  construction  of  this  piece  of  mechanism,  its  peculiar 
adaptability  to  the  end  designed  must  certainly  strike  any  one ;  a 
single  weak  point  being  the  reamings  used  as  supports  to  the  spurs, 
— an  objection  which  may,  however,  in  many  instances,  be  obviated 
by  receiving  the  spur  between  a  double  ligature  of  gilling  or  book- 
binder's twine. 

The  moving  of  the  teeth  accomplished,  the  apparatus  may  at 
once  be  removed,  the  parts  being  maintained  in  their  new  position 
by  fitting  a  plate  covering  the  whole  roof  of  the  mouth,  acting 
like  a  wedge  in  its  relation  to  the  common  arch.  Fig.  211  exhibits 
such  a  retaining  plate. 

Still  another  means  of  enlarging  an  arch  to  afford  room  for 
outlying  cuspidati  consists  in  adapting  to  the  lower  denture  an 
accurately-fitting  envelope  of  metal,  from  the  articulating  face  of 
which  pass  upward  and  inward  springy  flat  spurs,  against  which, 
in  the  act  of  occlusion,  the  superior  teeth  close,  thus  being  directed 
outward,  and  to  such  extent  spreading  the  parts.  A  spur,  of  course, 
is  not  to  strike  either  of  the  eye  teeth. 

Passing  here  to  another  study,  a  case  may  be  presented  where, 
with  room  in  the  arch,  the  lateral  incisors  maintain  a  posterior  posi- 
tion. 

Fig.  199  exhibits  such  a  condition.  This  is  an  irregularity  capable 
of  quick  correction,  as  exemplified  in  the  use  of  the  bar  (Fig.  200). 
This  bar,  being  adapted  to  the  labial  face  of  the  teeth,  is  held  in 
position  by  silk  ligatures  bound  tightly  to  the  misplaced  teeth.  A 
great  improvement  on  the  silk,  however,  as  has  been  shown  by  Dr. 
J.  H.  MtQuillen,  consists  in  the  substitution  of  india-rubber  rings, 


IBREGULARITIES  OF  THE   TEETH. 


485 


applied,  as  will  be  understood  by  referring  to  the  diagram,  by  being 
slipped  into  the  holes  through  file  cuts  made  from  the  face  of  the  bar. 


Fig.  199. 


Another  study  is  presented  in  Fig.  201.    Here,  it  is  seen,  a  central 
incisor  is  out  of  the  arch.   To  correct  this  deformity  a  very  common 


Fig.  201. 


and  very  satisfactory  practice  is  that  exhibited.  This  consists  in  an 
india-rubber  ring  thrown  about  the  projecting  tooth,  being  stretched 
back  until  it  reaches  a  bicuspis,  around  which  it  is  placed.  In  thus 
employing  the  elastic  ring,  it  will  not  unfrequently  be  found  that 
undue  strain  is  exerted  upon  the  base-tooth,  making  it  quickly  very 
sore.  In  these  cases  the  ring  is  to  be  changed  to  other  teeth,  or 
assistance  may  be  rendered  by  relieving  the  first  tooth  of  an  excess 
in  strain  by  dividing  the  work  by  means  of  a  ligature  carried  to 
some  back  tooth. 

Fig.  202,  a  case  from  the  practice  of  Dr.  J.  Foster  Flagg,  exhibits 


486 


OBAL  DISEASES  AND   SURGERY. 


another  deformity.     Here,  as  is  seen,  irregularity  exists  in  both 
arches.     "  The  treatment  consisted  in  removing-  all  the  second  bicus- 

FiG.  202. 


pids,  above  and  below,  and  throwing  india-rubber  tubing  ligatures 
around  the  six-year  molar  left  inferiors,  and  the  left  inferior  first 
bicuspid  and  cuspid,  drawing  the  two  latter  backward  into  the  arch, 
at  the  same  time  passing  a  silk  ligature  around  the  lower  incisors 
(Fig.  203)  in  such  manner  as  to  force  into  position  an  overlapping 


Fig.  204. 


Fig  203 


central.  In  the  upper  jaw  a  plate  (not  a  necessity)  was  adapted  to 
the  palate,  secured  by  silk  ligatures  to  the  first  permanent  molars. 
Pins  were  placed  in  the  plate  in  such  manner  as  to  allow  of  the 
attachment  of  two  elastic  bands,  which  were  secured  by  silk  threads 


IRBEGULARITIES   OF  THE   TEETH. 


487 


to  the  central  incisors  (Fig.  204),  drawing  upon  the  mesial  face. 
Other  bands  were  so  arranged  as  to  draw  upon  each  lateral  angle  of 
the  centrals,  passing  between  the  centrals  and  laterals  from  their 
palatine  faces,  and  running  along  the  labial  and  buccal  faces  unto  the 
first  molar  of  either  side.  Tubing  was  tiirown  around  the  remaining 
superior  bicuspid  of  either  side  and  the  molar,  for  the  purpose  of 
approximating  these  teeth,  thus  affording  space  for  the  proper  placing 
of  the  irregular  centrals.  By  this  arrangement,  nine  ligatures  were 
exercising  traction  at  the  same  time,  gradually  and  beautifully  per- 
forming their  work  of  correction  (Fig.  205).     With  the  view  of  pre- 

FiG.  20.5. 


venting  periosteal  irritation  from  becoming  periostitis,  both  local  and 
constitutional  treatment  was  adopted,  as  the  exigencies  of  the  case 
seemed  to  require.  Gentle  purgatives,  as  derivants,  and  tinct.  aco- 
niti  rad.,  were  used;  chlo.  potas.  and  plumb,  acet.  as  local  antiphlo- 
gistics,  and  solution  of  aqua  ammo.  con.  as  an  antacid.  The  cure 
was  effected  in  just  two  months,  and,  as  the  patient  averred,  with- 
out any  pain  or  inconvenience  worth  mentioning." — Description  by 
operator. 


Another  study,  to  which  attention  may  be  directed  as  being  a 
quite  common  condition,  resides  in  that  articulation  in  which  the 
anterior  teeth  of  the  superior  jaw,  in  place  of  overriding  the  inferior, 
close  directly  upon  them.  This  manner  of  bite,  when  found  in 
elderly  persons,  is  not  to  be  remedied  by  any  change  in  the  position 
of  the  teeth,  but  by  the  adoption  of  some  mechanical  device,  which 


488 


ORAL  DISEASES  AND  SURGERY. 


Fig.  206. 


shall  relieve  the  organs  of  the  abrading  influence  to  which  they  are 

subjected,  and  which,  unrelieved,  will  wear  them  to  the  gums. 

To  treat  such  a  malarticulation,  three 
modes  have  been  employed :  one  con- 
sisting in  a  metal  cap  inclosing  the  molar 
teeth,  this  keeping  the  anterior  teeth 
apart  and  taking  the  strain  of  mastica- 
tion ;  a  second,  a  cap  to  be  worn  over 
the  front  teeth  while  eating  (Fig.  206)  ; 
and  third,  the  cutting  of  cavities  in  the 

antagonizing  faces  of  the  abrading  teeth,  and  building  thereon  faces 

of  gold. 

Fig.   20T  exhibits  a  malarticulation  known   as  "underhung," — 


Cap  for  Front  Teeth. 


FiQ.  207. 


the  teeth  of  the  lower  arch  closing  beyond  the  upper.  To  correct 
such  a  deformity,  different  operators  employ  difiFerent  means.  Such 
a  case  presenting,  a  first  consideration  is  as  to  the  nature  and  cause 
of  the  condition. 

Protrusion  of  the  inferior  teeth  may  exist  from  a  variety  of  causes. 
The  jaw  itself  may  be  elongated,  the  angle  being  too  obtuse  for  the 
age.  The  body  of  the  lower  jaw  may  be  out  of  proportion  to  the 
upper.  The  teeth  themselves  may  unduly  spread  or  evert.  The 
fault  may  be  in  the  superior  denture. 


IRREGULARITIES   OF   THE    TEETH. 


489 


Fig.  208. 


.^ 


9 


An  anatomico-physiological  examination  of  the  inferior  maxilla 
exhibits  a  body  and  ramus  whose 
angle  of  relation  varies  with  the 
age  of  the  patient,  or  some  other  in- 
fluencing circumstance.  At  a  very 
obtuse  angle  in  young  life,  it  passes 
to  the  right  angle  in  adult  life,  to 
fall  again  into  the  obtuseness  on 
the  approach  of  old  age  and  the 
loss  of  the  teeth.  The  three  speci- 
mens (Fig.  208)  represent  these 
varying  conditions, — the  first,  the 
infant  bone,  being  very  obtuse;  the 
second,  the  adult,  being  at  a  right- 
angled  relation  ;  the  third,  the  bones 
of  an  edentalous  old  person,  having 
the  ramus  almost  on  a  plane  with 
the  body. 

In  a  young  patient  having  a 
protruded  under  jaw,  the  size  of  the  upper  jaw  and  the  position  of  the 
teeth  being  normal,  advantage  is  to  be  taken  of  the  natural  tendency 
of  the  parts  to  retire  ;  a  sling, — the  occipito-mental, — the  straps 
being  of  elastic  material,  is  to  be  used,  as  represented  in  Fig.  209. 
Such  a  sling,  properly  made  and  applied,  will  be  found  to  exert  such 
constant  pressure  on  the  angle,  forcing,  as  it  does,  the  body  back- 
Ward,  that  not  unfrequentl}'  a  very  few  months  will  suffice  to  correct 
such  a  malarticulation,  and  this  without  discomfort  or  the  possibility 
of  ill  consequences. 

Where  fault  resides  in  the  superior  arch,  the  jaw  itself  being  small, 
or  the  teeth  being  possessed  of  inlooking  cutting  faces,  the  appliance 
represented  in  Fig.  209  may  be  used,  or  the  envelope,  with  the  flat 
spurs,  may  be  employed,  as  directed  for  use  upon  the  lower  denture 
(Catalan's  inclined  plane). 

A  mode  of  treating  a  case  of  malarticulation  such  as  is  exhibited 
in  Fig.  207 — this  cut  being  indeed  a  model  taken  from  this  special 
mouth — has  been  practiced  after  the  following  manner  with  a  suc- 
cess as  exhibited  in  Fig.  210,  by  Dr.  Norman  Kingsley. 

The  external  features  of  this  case,  says  Dr.  Kingsley,  showed, — 

"  1st.  That  the  lower  jaw  was  not  too  large,  being  neither  too  wide 
nor  too  long.  This  determination  was  easily  arrived  at  by  a  com- 
parison of  the  extreme  lower  part  of  the  face  with  the  upper  part  of 


490 


ORAL  DISEASES  AND   SURGERY. 


the  face  and  head.  2d.  The  same  course  of  reasoning  showed  that, 
relatively,  the  upper  alveolar  border  and  row  of  teeth  were  con- 
tracted so  much  as  to  produce  limited  external  deformity. 

Fig.  209. — Occipito-Mental   Sling. 


"To  a  casual  observer,  the  chin  and  lower  lip  were  too  full.  To  a 
more  accurate  observer,  the  upper  lip,  cheeks,  and  nose  were  de- 
pressed. I  suggested  that  immediate  attention  would  correct  what 
otherwise  would  become  an  increasing  deformity  through  life. 

"  The  casts  as  represented  in  Fig.  207  were  taken,  and  the  first 
fixture  applied,  January  19.  Six  days  afterward  the  incisor  teeth 
of  the  upper  jaw  were  overlapping  the  lower  incisors. 

"  On  that  same  day,  namely,  January  25,  I  gave  a  clinic,  by  pre- 


IRREGULARITIES   OF   THE    TEETH. 


491 


vious  engagement,  under  the  auspices  of  the  District  Dental  Society 
of  New  York,  on  the  subject  of  '  Treatment  of  Irregularities,'  and 
I  took  an  impression  and  made  a  cast  of  this  case,  exhibiting  it  there 
as  a  part  of  my  demonstration,  to  prove  the  rapidity  with  which 
teeth  could  safely  be  moved  into  certain  positions. 

"Within  twenty  days  from  the  time  the  power  was  first  applied  to 
the  teeth,  the  entire  upper  row  was  articulating  outside  of  the  lower 
ones,  substantially  as  shown  in  Fig.  210.     A  retaining  plate  was 

Fig,  210. 


Fig.  211. 


adapted  to  the  upper  jaw,  such  as  is  shown  in  Fig.  211,  which  was 
worn,  with  some  unimportant  modifications,  for  several  months. 

"  The  result  is  a  most  marked 
change  in  the  profile,  and  in  the 
relation  of  the  external  features. 
The  individual  features  being  natu- 
rally well  formed  and  symmetrical, 
the  change  in  their  relations  pro- 
duced a  face  of  more  than  usual 
beauty. 

"  The  treatment  consisted  solely 
of  wedges  inserted  between  the 
teeth,  as  shown  in  Fig.  212,  in  con- 
junction with  the  retaining   plate, 

Fig.  211.  Wedges  were  inserted  between  all  the  teeth,  and  worn 
from  the  first.  These  wedges  were  of  elastic  rubber,  and  used 
of  such  thickness  only  as  would  exert  a   gentle   pressure;      The 


492 


ORAL   DISEASES  AND   SURGEBY. 


retaining  plate  answered  a  twofold  purpose:  first,  it  kept  the  teeth 
from  the  possible  contingency  of  any  one  of  them  moving  toward 


Fig.  212. 


the  centre  of  the  mouth  ;  and,  secondly, — what  was  of  equal 
importance, — points  of  the  retaining  plate  were  allowed  to  pass 
between  all  the  teeth,  which  kept  each  wedge  from  slipping  up  into 
and  irritating  the  gum. 

"  The  patient  was  watched  daily  so  long  as  the  wedges  were  acting. 
When,  by  reason  of  their  want  of  thickness,  they  ceased  to  act,  new 
ones,  but  slightly  thicker,  were  substituted.  There  was  no  more 
discomfort  to  the  patient  undergoing  this  process  than  is  commonly 
experienced  in  the  wedging  of  one  or  two  teeth  in  the  mouth  for  the 
purpose  of  getting  space  for  filling.  There  was  no  soreness  which 
called  out  complaint  from  the  patient.  There  was  no  favoring 
diet,  nor  was  there  any  provision  made  for  masticating  while  the 
teeth  were  in  transit. 

"  The  teeth  in  their  new  position  and  articulation,  as  seen  in  Fig. 
210,  have  remained  stationary  now  for  a  period  of  three-quarters  of 
a  year.  Not  only  is  the  external  face  improved,  but  a  longevity  is 
guaranteed  to  these  teeth  by  their- isolation  which  could  not  have 
been  obtained  by  any  other  means. 

"  The  foregoing  statement  is  not  put  forward  as  the  report  of  a  case 
to  prove  what  is  sometimes  possible,  or  what  trials  nature  may  un- 
dergo and  still  survive,  but  it  is  set  forth  as  an  illustration  of  a  prin- 


\ 


IRREGULARITIES  OF   THE    TEETH.  493 

ciple  in  the  treatment  of  irregularities  which  has  never  before  been 
published.  I  have  heretofore  claimed  something  for  aesthetic  art  in 
the  practice  of  dentistry  ;  for  the  above  I  claim  nothing  but  a  recog- 
nition of  pure  mechanical  principles  in  dental  practice.  The  wedge 
is  one  of  the  recognized  mechanical  powers.  Its  application  here  is 
identical  with  its  use  by  the  architect  for  a  keystone  in  building  his 
arch.  Drive  in  the  keystone,  and  the  arch  is  necessarily  enlarged, 
and  will  continue  to  be  enlarged  so  long  as  a  wider  keystone  is  ad- 
missible and  there  is  a  support  which  will  prevent  the  whole  arch 
from  tumbling  in  ruin  to  the  centre." 

In  attempting  the  correction  of  a  deformity  as  here  suggested 
by  Dr.  Kingsley,  special  regard  would  necessarily  have  to  be  had 
to  the  more  immediate  results.  Without  doubt  the  wedge  is  a  most 
important  means  to  the  correction  of  an  irregular  denture,  but  it  is 
an  agent  capable  of  doing  so  much  harm  through  the  irritability  it 
provokes,  that  the  cases  must  be  few  indeed  in  which  it  could  be 
so  largely  made  use  of  as  in  the  instance  just  considered.  This  par- 
ticular case  is  employed,  however,  as  an  illustration,  not  that  it  may 
be  commended  to  the  inexperienced,  but  rather  to  exhibit  what  judg- 
ment, aided  by  the  most  simple  of  appliances,  may  accomplish. 

A  very  simple  and  not  unfrequently  effectual  mode  of  correcting 
the  deformity  of  protruding  lower  teeth  in  young  patients,  applica- 
ble particularly  where  the  organs  close  directly  against  each  other, 
consists  in  removing  from  the  inferior  arch  the  first  bicuspidatus  of 
either  side,  which  begets  in  the  patient  a  habit  of  pushing  the  chin 
backward ;  or  the  latter  purpose  will  be  answered  by  wearing  the 
occipito-mental  sling  during  mealtime. 

Among  the  various  appliances  which  ingenuity  has  suggested  for 
the  treatment  of  dental  irregularities,  is  a  plate  devised  by  Dr.  Red- 
man, of  Cincinnati.  This  is  a  rubber  cap  accurately  fitting  the  pala- 
tine arch  and  carried  across  the  anterior  face  of  the  teeth,  having 
thus,  as  is  seen,  a  most  secure  relation.  Where  it  is  desired  to  move 
a  particular  tooth,  the  plate  is  cut  away  in  the  direction  which  it  is 
desired  the  tooth  shall  take,  pressure  being  brought  to  bear  from  the 
opposite  point  by  wedges  of  wood  forced  through  holes  in  the  plate. 

In  correcting  irregularities  of  the  teeth,  it  is  always  necessary  to 
bear  in  mind  the  antagonism  which  may  exist  to  the  moving  force 
as  relation  is  had  to  the  articulation.  A  tooth  bound  in  place  by  one 
overlying  may  only  be  moved  through  relief  from  the  existing 
pressure.     To  insure  such  relief  it  is  found  necessary,  in  almost  all 


494  ORAL  DISEASES  AND   SURGERY. 

cases,  so  to  cap  neighboring  teeth  as  to  compel  a  space  between  the 
two  ai'ches, — such  space  to  be  preserved  until  the  tooth  is  changed 
to  its  new  position,  when  the  removal  of  the  cap  and  the  restoration 

of  the  articular  bite  will,  in  many 
Fig.  213.  instances,    prove    the    best   means 

that  can  be  adopted  for  securing 
permanency  to  the  change.  Fig. 
213  represents  a  principle  found 
most  useful  in  a  great  variety  of 
cases  of  dental  irregularities.  An 
example  of  its  application  may  be  given  as  follows : 

Case. —  Two  central  incisors  turned  u2)on  their  axes  and  over- 
wrappiyuj  ;  arch  narrow  and  croicded. — To  turn  teeth  so  situated, 
a  first  necessity  is  room.  To  secure  this  room  the  arch  must  be 
widened.  Examination  of  the  instrument  exhibits  double  collars 
for  resting  against  teeth  on  opposite  sides  of  the  arch:  these  collars 
are  attached  to  screw-cut  tubes  I,  2,  which  tubes  are  associated  by 
a  common  screw,  3.  Desiring  to  widen  the  arch  and  thus  afford 
facility  for  manipulating  the  crowded  incisors,  the  collars  are  placed 
against  the  inner  faces  of  the  teeth  designed  to  be  moved,  when, 
by  means  of  a  wrench,  the  screw  is  turned,  the  arms  being  extended 
day  by  day  as  circumstances  permit.  The  desired  space  thus  secured, 
a  plate  is  fitted  to  insure  retention  of  the  teeth  in  the  new  position, 
when  the  teeth  may  be  turned  into  proper  position,  as  practiced 
in  the  example  from  Dr.  Flagg. 

Illustrating  the  use  of  this  means  in  another  instance,  reference 
may  be  made  to  lateral  incisors,  or  other  teeth  fallen  within  the  arch 
and  overlaid  by  their  fellows.  Here  application  of  the  enlarging  force 
is  made  in  the  same  manner.  When  the  proper  room  has  been 
secured,  the  misplaced  tooth  may  with  all  facility  be  drawn  into 
place  by  the  labial  plate  and  elastic  ring,  as  before  described,  a 
manipulation  which  would  be  impossible  without  the  previous 
expansion. 

Kepeating  to  the  reader  the  conviction  that  the  principles  of  or- 
thodontia are  of  much  more  consequence  than  a  knowledge  of  special 
appliances,  the  subject  may  be  left  with  assurance  that  the  illustra- 
tions given  are  all  that  can  be  needed  to  afford  the  requisite  hints 
for  the  government  of  such  special  or  peculiar  cases  as  may  from 
time  to  time  be  met  with. 


CHAPTER    XXI L 


DISEASES     OF     THE     TEETH. 


SALIVAKY  CALCULUS. 


Salivary  Calculus,  or  tartar,  as  it  is  commonly  called,  is  that 
limelike  material  so  often  seen  collected  about  the  necks  of  the  teeth. 
Observation  elicits  the  fact  that  the  primary  seat  of  deposit  is  about 
the  posterior  or  lingual  faces  of  the  inferior  central  teeth  and  the 
buccal  aspect  of  the  superior  molars ;  and  as  in  these  situations 
exist  the  outlets  of  the  salivary  secretions,  the  inference  is  that  from 
such  secretions  comes,  in  part  at  least,  the  deposit. 

Analysis  of  Saliva.  Analysis  of  Salivary  Calculus. 

Water.  Carbonate  of  lime. 

Ptyalin.  Phosphate  of  lime. 

Fat.  Fat. 

Chloride  of  sodium.  Mucus. 

Chloride  of  potassium.  Accidental  matter. 
Phosphate  of  lime. 
Sulpho-cyanide  of  potassium. 

When  thd  salivary  secretions  are  sluggish,  the  inorganic  material, 
not  being  held  in  solution  until  fairly  ejected  into  the  mouth,  becomes 
deposited  about  the  roughened  and  inviting  surfaces  of  immediately 
neighboring  teeth.  A  nucleus  once  fairly  formed,  aggregation  goes 
on,  until  serious  secondary  lesions  are  apt  to  result. 

The  first  and  most  marked  effect  of  salivary  calculus  is  upon  the 
teeth  themselves;  beginning  upon  one  face,  it  soon  involves  the 
whole  organ,  and,  if  undisturbed,  envelops,  sooner  or  later,  in  an 
imperfect  sheath,  the  whole  denture.  A  mouth  so  filled  with  tartar 
is  not  only  disgusting,  but  necessarily  also  in  an  unhealthy  con- 
dition. Salivary  calculus  soon  destroys  the  integrity  of  the  teeth. 
It  does  this  by  its  effects  on  the  secretory  crypts  about  their  necks 
and  by  compelling  the  gradual  diminution  of  the  periosteal  supply; 
this  membrane  dying  little  by  little  as  the  foreign  body  encroaches 

(495) 


9^ 


496  OBAL  DISEASES  AND   SURGERY. 

on  it.  As  a  result  of  such  abstraction  of  nutrition,  the  tooth  soon 
dies,  and  is  exfoliated  like  any  other  sequestrum  ;  tooth  after  tooth 
necrosing,  and  each  mouth  or  year  one  or  more  dropping  from  its 
socket. 

Not  unfrequently  there  may  be  seen  standing,  isolated  and  alone, 
on  some  portion  of  the  dental  arch, — most  frequently,  however, 
either  on  the  anterior  portion  of  the  inferior  arch,  or  the  posterior 
portion  of  the  superior, — a  yellowish-looking  tumor,  which  might 
not  inaptly  be  compared  to  a  shellbark  covered  with  inspissated 
mucus.  Sometimes  this  tumor  will  be  found  quite  firm  in  its  po- 
sition, seeming,  indeed,  as  if  it  might  have  sprung  from  the  socket 
of  some  long-ago-extracted  tooth;  at  other  times  you  will  be  able 
-to  move  it  quite  freely,  as  if  it  had  a  fleshy  peduncle.  These  tumors 
give  to  the  patient  a  most  disagreeable  appearance,  are  oftentimes 
insufferably  offensive,  and  so  detriaiental  to  health  that  five  or  six 
grains  of  their  substance,  given  to  a  small  animal,  will  not  unfre- 
quently cause  its  death.  The  composition  of  such  tumors  consists 
of  phosphate  and  carbonate  of  lime,  epithelial  scales,  inspissated 
mucus,  and  the  various  detritus  of  a  cavity  devoted  to  mastication. 
In  other  words,  they  are  calculi.  The  nucleus  of  such  growth  is  of 
course  a  tooth.  The  manner  of  formation  is  too  evident  to  need 
description.  I  have  removed  these  calculi,  where  the  nucleus  had 
become  so  encysted,  from  crown  to  apex,  that  no  trace  of  it  was  to 
be  discovered  without  dividing  the  mass.  Where,  however,  the 
encystment  has  advanced  to  this  extent,  the  tumor  is  about  ready 
to  drop  from  the  mouth.  I  have  seen  a  calculus  of  this  kind  encyst 
the  six  lower  front  teeth,  making  as  strange  a  looking  tumor  as 
could  be  well  imagined. 

Similar  calculi  develop,  as  may  be  inferred,  in  other  parts  of  the 
mouth.  Thus,  just  within  the  orifice  of  the  duct  of  Steno  they  may 
occasionally  be  found  ;  the  tumor,  in  such  a  case,  bulging  out  from 
the  cheek  against  the  second  molar  tooth  of  the  upper  jaw.  The 
formation  of  such  tumors  in  these  situations  does  not  necessarily 
imply  the  closure  of  the  orifice  of  the  duct:  they  form  when  the 
gland  is  sluggish  ;  the  secretion  not  being  in  sufficient  abundance  to 
bold  the  lime  of  the  saliva  in  solution  until  it  is  ejected  from  the 
duct,  it  falls  on  the  floor  of  the  duct,  and,  lodging,  makes  the 
nucleus. 

I  remember,  on  one  occasion,  having  been  called  by  a  fellow- 
practitioner  to  see  a  case  where  a  mass  of  this  calcareous  matter, 
fully  the  size  of  the  largest  almond,  seemed  to  be  growing  from  all 


SALIVARY  CALCULUS.  497 

that  portion  of  the  sublingual  region  anterior  to  the  gland  of  that 
name;  one-half  the  tumor  looked  as  if  it  might  be  below  the  level 
of  the  floor  of  the  mouth,  the  mucous  membrane  enveloping  the  mass 
with  ragged  and  ulcerated  edges.  It  certainly  presented  a  very 
strange  and  threatening  look.  My  friend  was  deceived  as  to  its 
character,  because  there  was  no  apparent  direct  association  between 
the  tumor  and  the  neighboring  teeth,  and  because  it  was  as  firmly 
fixed  as  though  it  might  have  been  a  growth  springing  from  neigh- 
boring bone.  Yet  this  was  a  salivary  calculus  and  nothing  else,  the 
only  question  being  as  to  its  cause  and  fixedness. 

Looking  about  the  mouth,  T  perceived  that  the  patient  had  certain 
artificial  teeth  on  the  left  side  of  the  arch  ;  these  teeth  were  all  coated 
with  tarta,r,  and  so  associated  thereby  with  the  natural  teeth  as  to 
be  only  distinguishable  by  that  difference  in  the  translucency  so 
immediately  noticeable  by  any  one  experienced  in  such  direction. 
Knowing  well  that  it  is  a  plan  with  many  dentists  to  secure  such 
teeth  by  passing  a  strong  gold  wire  across  the  mouth,  and  which 
wire  not  unfrequently  buries  itself  within  the  mucous  membrane, 
thereby  occasionally  becoming  concealed,  I  inferred  at  once  that  this 
would  be  found  the  nucleus  of  the  calculus,  and  accordingly  so 
directed  an  examination.  This  was  commenced  by  cutting  away 
the  calculus  from  about  the-  artificial  teeth,  and,  as  anticipated,  the 
band  was  revealed ;  next  was  sought  the  concealed  attachment  of 
the  opposite  side,  and  this  being  discovered  and  exposed,  the  two 
ends  were  forced  from  the  teeth  which  they  clasped,  and  thus  the 
artificial  teeth,  wire,  and  calculus  were  lifted  from  the  mouth  in  a 
body. 

The  site  of  the  calculus,  as  may  be  inferred,  presented  a  cup- 
shaped  ulcerated  depression,  and  was  quite  angry-looking. 

The  only  after-treatment  consisted  in  the  use  of  an  astringent 
wash.     The  ulceration  healed  kindly  in  a  very  few  days. 

It  may  be  suggested  that  the  existence  of  such  calculi  is  not  an 
unfrequent  cause  of  dyspeptic  and  other  alimentary  troubles.  I 
have  just  now  in  my  mind  the  memory  of  a  case  of  dyspeptic  con- 
sumption very  illustrative. 

In  her  mouth,  the  patient,  a  lady,  had  but  a  single  tooth,  and 
this  for  years  had  been  so  imbedded  in  salivary  calculus  as  much 
more  to  resemble  a  half-rotted  shellbark  than  a  tooth, — her  breath 
was  made  insufferable  by  it.  I  removed  the  offensive  mass,  and  the 
recovery  of  the  patient  was  really  magical  in  its  rapidity. 

Such  calculi  are  to  be  removed  in  any  convenient  manner :  they 

32 


498  ORAL  DISEASES  AND  SURGERY. 

may  be  pulled  away,  broken  in  pieces,  or,  when  loose,  may  be  cut 
from  the  gum  ;  the  operation  being  entirely  a  mechanical  one,  and 
of  course  very  simple. 

I  forget,  however,  in  such  advice,  reference  to  calculi  situated. in 
the  salivary  ducts.  These  are  to  be  removed,  either  by  enlarging 
the  orifices  and  crushing  the  stones,  or  by  cutting  down  upon  them 
at  the  most  convenient  point.  When  so  cut  upon,  the  wound  will 
not  commonly  require  any  after-attention. 

The  existence  of  salivary  concretions  in  the  ducts,  particularly  the 
Whartoniau,  is  not  at  all  unfrequent ;  indeed,  they  are  occasionally 
to  be  met  with  in  the  substance  of  the  glands  themselves.  A 
specimen,  extracted  from  the  submaxillary  gland,  had  its  diagnosis 
in  a  continuous  issue  of  pus  from  the  tubal  outlet.  A  second  instance 
is  on  record  where  the  glands  of  either  side  were  found  stuffed  with 
calculi.  When  situated  in  the  ducts,  the  sense  of  touch,  exhibiting 
the  hardness  and  irregularity  of  the  body,  will  not  unfrequently 
afford  recognition  of  the  condition.  Where,  however,  the  enveloping 
tissues  have  become  infiltrated  and  thickened,  a  diagnosis  by  such 
means  is  rendered  obscure,  and  is  perhaps  to  be  secured  only  by 
passing  into  the  tumor  the  point  of  a  delicate  bistoury,  or  the  ex- 
ploring-needle. 

In  the  case  of  a  calculus  in  the  substance  of  the  submaxillary 
gland,  met  with  by  the  author  in  his  own  practice,  a  happy  cure 
was  effected  by  working  the  stone  to  a  presentation  upon  the  floor 
of  the  mouth,  secured  by  depressing  the  chin  upon  the  neck  and 
thrusting  the  gland  from  without  upward.  Knowledge  of  the  exact 
po.'^ition  thus  secured,  a  single  cut,  passing  through  the  mucous 
membrane  and  mylo-hyoideus  muscle  into  the  substance  of  the 
gland,  reached  the  body,  which,  with  some  little  trouble,  was  se- 
cured in  the  grasp  of  the  forceps  and  removed.  In  size  this 
calculus  was  about  the  circumference  of  a  hazel-nut.  The  wound 
made  healed  completely  after  a  week,  and  the  patient  had  no  future 
trouble. 

An  interesting  and  most  suggestive  case  in  this  direction  has  the 
following  record  : 

Mrs.  Boyd,  a  lady,  sixty-nine  years  of  age,  residing  on  Sansom 
Street,  West  Philadelphia,  applied  to  the  author,  being  directed  by 
some  unknown  professional  friend,  concerning  a  tumor  of  the  mouth, 
from  an  inflamed  condition  of  which  she  was  at  the  time  enduring 
much  suffering. 

Ocular   inspection   revealed   the  following   condition :    a  tumor. 


SALIVARY  CALCULUS.  499 

very  scirrhus-like,  hard,  lobulated,  and  angry-looking,  occupied  all 
that  portion  of  the  floor  of  the  mouth  to  the  right  of  the  mesial  line ; 
general  inflammation  of  the  whole  oral  cavity,  to  such  extent  as  to 
make  mastication  too  painful  to  be  practiced,  and  to  render  deglu- 
tition very  difficult.  All  the  teeth  in  the  neighborhood  loose,  and 
occupying  irregular  positions, — the  result  evidently  of  a  hyperplastic 
condition  of  the  alveolo-dental  membranes.  The  superficial  cervical 
glands,  especially  those  of  the  submaxillary  I'egion,  sympathizing  to 
a  considerable  extent ;  while  the  submaxillary  gland  itself  was  so  en- 
larged as  to  render  it  sufficiently  prominent  to  be  easily  mapped  out. 

The  patient  seeming  unable  to  talk  of  anything  except  her  present 
great  pain,  which  she  described  as  cutting,  tearing,  burning,  the  case 
was  dismissed  for  the  day,  after  prescribing  for  an  immediate  relief, 
— namely,  the  ordering  of  leeches,  aperients  combined  with  Dover's 
powder,  astringent  local  applications,  etc. 

Two  days  after,  the  patient  was  again  seen.  The  general  inflam- 
mation was  resolving  very  rapidly,,  while  the  mental  equilibrium 
was  quite  restored. 

This  disease  had  been  pronounced  cancer  by  several  gentlemen, 
and  advice  given  that  no  application  of  any  kind  should  be  made; 
that  the  patient  should  not  even  permit  the  tumor  to  be  handled  for 
any  further  examination.  Under  such  impression  as  to  its  char- 
acter, the  lady  had  given  up  all  hope  of  permanent  relief. 

The  history  of  the  case  is  as  follows : 

Eighteen  years  before,  while  engaged  in  milking  an  intractable 
cow,  a  kick  was  received  under  the  chin,  so  severe  in  character  as  to 
compel  a  confinement  to  bed  for  over  two  weeks.  This  trouble  gotten 
through,  the  parts  soon  recovered  their  natural  tone,  and  seemed  as 
well  as  ever. 

But  little  more  than  nine  months  had  passed,  however,  when  the 
patient  was  made  conscious  of  occasional  slight  inflammatory  attacks 
about  the  region  of  the  sublingual  gland.  These  attacks  continued  to 
grow  in  frequency  and  extent,  terminating,  to  use  her  own  language, 
"  by  a  something  which  looked  like  a  whitish  worm,  coming  from 
somewheres,  into  her  mouth."  This  worm,  she  said,  "  was  always 
the  assurance  to  her  of  immediate  relief." 

The  trouble  continued  to  recur  for  over  a  year,  when  a  tumor 
began  to  develop  in  the  parts.  The  inflammatory  attacks  now  de- 
creased in  number,  but  increased  in  severity, — the  patient  noticing 
that  after  each  inflammation  the  size  of  the  original  tumor  was 
augmented. 


500  ORAL  DISEASES  AND   SURGERY. 

So  the  case  ran  on  for  a  period  of  several  years.  It  was  re- 
marked, however,  nearly  ten  years  back,  that  the  tumor  had  ceased 
to  enlarge  from  the  inflammatory  attacks,  having  at  that  time  gained 
the  size  of  a  pullet's  egg,  and  neither  increasing  nor  decreasing  up 
to  the  time  of  my  examination.  Reference,  of  course,  is  made  to 
the  tumor  in  a  quiescent  state,  for  each  succeeding  inflammation 
swelled  all  the  parts,  tumor  included,  temporarily,  more  than  the 
one  which  had  preceded  it. 

The  patient's  general  health  was  quite  good ;  there  was  no  con- 
stitutional evidence  to  be  perceived  of  a  cachexia. 

Now,  while  the  history  of  this  tumor,  in  its  local  features,  was  in 
many  points  the  history  of  cancer,  yet,  considering  its  location,  con- 
sidering the  affection  of  the  gland  duct,  which,  as  indicated  by  the 
story  of  the  worm,  evidently  had  association  with  the  tumor;  con- 
sidering the  inflammatory  attacks  to  which  the  parts  had  been  so 
frequently  subjected,  and  which  had  resolved  harmlessly  ;  consider- 
ing the  length  of  time  the  tumor  had  existed,  without  passing  or 
apparently  tending  to  pass  to  the  ulcerative  stage ;  considering 
these  features  in  a  diagnostic  point  of  view,  it  seemed  necessarily 
decided  that  the  tumor  was  of  local  signification,  and  not  a  cancer. 

What  then  was  it?  The  trouble  commenced  evidently  as  in- 
spissated ranula.  My  conviction,  founded  on  the  history,  was,  that 
it  was  still  a  ranula.  Not  ranula,  as  derivatively  we  understand 
the  meaning  of  that  word,  but  rauula,  as  pathologically  the  term 
has  association  with  the  salivary  ducts.  What  the  contents  of 
such  cyst,  if  cyst  there  was,  might  be,  I  did  not  feel  prepared 
absolutely  to  decide. 

Acting  on  the  strength  of  this  conclusion,  I  suggested  to  the 
patient  my  impressions,  and  requested  to  be  allowed  to  pass  a 
bistoury  through  the  parts.  This,  however,  met  with  a  most  de- 
cided negative, — the  refusal  not  being,  perhaps,  so  very  strange, 
considering  the  assurance  that  Mrs.  B.  had  so  often  received,  that 
any  attempt  to  operate  would  be  her  death-warrant. 

Failing  in  several  other  attempts  at  persuasion,  I  became,  at  length, 
annoyed  at  the  obstinacy  of  the  patient,  and  dismissed  the  case. 

About  a  month  after,  however,  prompted  by  curiosity,  I  called 
again  on  Mrs.  Boyd.  There  was  now  not  the  slightest  evidence  of 
inflammation  about  the  parts.  The  tumor  was  about  the  size  of  a 
pullet's  egg,  hard  almost  as  stone,  and  distinctly  divisible  into 
three  lobes.  The  patient  assured  me  that,  with  the  exception  of  an 
occasional  sharp  pain,  she  felt  little  or  no  inconvenience. 


SALIVARY  CALCULUS.  501 

At  this  visit,  more  than  ever  satisfied  in  a  diagnosis,  an  explora- 
tion was  re-urged,  but  was  as  decidedly  refused  as  before. 

On  a  Saturday  morning  I  was  again  called  to  see  the  patient. 
She  was  suffering  from  another  of  the  inflammatory  attacks  ;  the 
most  severe  she  bad  yet  experienced. 

Examination  discovered  the  tumor  swollen  to  such  an  extent  as 
to  throw  the  tongue  over  into  the  left  cheek.  Mastication  had  been 
impossible  for  three  or  four  days,  while  the  ability  to  swallow  was 
being  very  rapidly  lost ;  yet,  with  all  this  inflammation,  there  seemed 
no  tendency  to  the  formation  of  abscess. 

Placing  the  old  lady  in  an  arm-chair,  before  the  window,  with- 
out asking  permission  or  offering  any  suggestion,  I  managed  to  get 
the  mouth  under  my  control,  and,  before  she  was  aware  of  the  in- 
tention, I  passed  a  bistoury  directly  through  the  body  of  the  tumor: 
the  knife  grated  over  some  hard  substance. 

After  a  time  spent  in  making  peace,  in  which  I  was  greatly  as- 
sisted by  the  assurance  I  was  enabled  to  give  of  the  discovery  which 
was  to  result  in  her  immediate  cure,  I  proceeded  to  the  dissecting 
out  of  the  foreign  body.  This,  as  anticipated,  proved  to  be  a  sali- 
vary calculus.  The  specimen  was  placed  in  possession  of  Prof.  D. 
H.  Agnew,  to  whom  I  presented  it  for  the  pathological  museum  of 
the  Philadelphia  Hospital,  and  is,  perhaps,  one  of  the  largest  on 
record. 

The  pathology  of  such  a  lesion  is  at  once  appreciated  :  the  forma- 
tion of  the  calculus  in  this  region  was  merely  secondary  to  the  oc- 
clusion of  the  mouth  of  a  gland  duct. 

Dr.  J.  J.  Woodward,  who  made  an  analysis  of  a  portion  of  the 
calculus,  informed  me  that  he  found  it  composed  almost  exclusively 
of  the  phosphate  of  lime,  only  a  very  small  trace  of  the  carbonate 
being  perceptible. 

I  saw  Mrs.  Boyd,  for  the  last  time,  one  month  later.  All  induration 
had  so  completely  disappeared  that  I  think  it  would  be  difficult  for 
any  one  who  had  not  seen  the  case  to  say  which  side  of  the  mouth 
the  tumor  had  been  removed  from ;  not  the  slightest  perceptible 
tendency  to  disease  being  visible. 

A  case  of  calculus,  interesting  from  its  rarity,  has  been  presented 
to  the  attention  of  the  French  Academy  of  Sciences,  in  which  a  con- 
cretion was  removed  from  a  sublingual  duct  of  an  infant  but  three 

weeks  old.     The  history  of  the  case  is  thus  given.     On  the , 

a  poor  woman  called  upon  Dr.  Burdel,  complaining  that  the  child 
could  not  take  the  breast,  which  she  attributed  to  its  being  tongue- 


502  ORAL  DISEASES  AND  SURGERY. 

tied.  Upon  examination,  Dr.  Burdel  did  not  discover  any  string  or 
ligament  of  undue  shortness,  but  found  the  sublingual  gland  so  ex- 
cessively developed  as  to  raise  the  tongue  considerably  from  the 
cavity  in  which  it  lies.  He  soon  discovered,  by  touching  the  tumor 
with  his  little  finger,  that  it  must  contain  a  hard  substance.  A  slight 
pressure  brought  to  light  the  extremity  of  a  calculus,  ending  in  a  fine 
point,  and,  after  some  unsuccessful  attempts,  he  succeeded  in  ex- 
tracting it  without  an  incision.  The  calculus  is  described  as  some- 
what of  an  egg-shape,  but  ending,  as  already  stated,  in  a  fine  point. 
Its  size  was  that  of  a  grain  of  wheat,  its  color  yellow,  its  surface 
granulous,  wrinkled,  and  formed  of  a  number  of  minute  cones  or 
paps,  cemented  together  at  their  bases. 

This  is  an  instance  of  a  salivary  calculus  formed  before  the  birth, 
when  the  saliva,  according  to  Dr.  Cloquet,  is  but  little  charged  with 
salts.  An  analysis  of  this  concretion  exhibited  it  as  being  composed 
almost  exclusively  of  tribasic  phosphate  of  lime  and  a  small  fraction 
of  nitrogenous  organic  matter,  which  must  have  been  mucus  from 
the  salivary  duct. 

As  seen  upon  the  teeth,  tartar  varies  markedly  in  color  and  con- 
sistence, being  sometimes  so  hard  and  closely  adherent  as  to  seem 
almost  a  part  of  the  tooth.  In  other  instances  it  is  found  soft,  and 
of  such  flaky  nature  that  the  slightest  effort  suffices  to  break  it  away 
in  bulk.  A  character  of  tartar  is  found  allied  with  the  mucoid,  or 
typh  condition,  being  of  pasty  consistence,  having,  perhaps,  a  truer 
expression  of  its  signification  in  the  term  sordes,  being  composed  of 
detritus,  combined  with  inspissated  mucus. 

In  color,  tartar  varies  from  a  dirty  white  to  black,  the  shade 
depending  on  the  temperament  of  the  individual,  yet  being  neces- 
sarily much  influenced  by  personal  habits.  In  the  sanguineo- 
bilious,  tendency  to  the  deposit  of  flaky  brown  tartar  is  very 
marked.  This  deposit  is  the  truest  expression  of  salivary  calculus, 
being  composed  almost  exclusively  of  the  constituents  of  the 
saliva. 

United  with  all  tartar  are  fungi.  Here,  as  truly  suggested  by 
Herr  Schrott,  do  the  infusoria  find  convenient  habitation,  remaining 
the  longest  time,  attaining  their  highest  age,  dying,  and  leaving 
their  limy  remnants  to  interlace  with  epithelial  scales,  parasites, 
remains  of  food,  slime,  and  secretions  of  saliva,  forming  in  this 
manner  the  tartar  of  the  teeth  :  assisting  to  form,  would  have  been 
the  truer  apprehension. 

That  all  tartar  is  not  salivarv  calculus  is  made  evident  enough 


SALIVARY  CALCULUS. 


503 


by  minute  examination.  The  deposit  about  the  teeth  of  the  scor- 
butic is  in  great  part  from  the  mucous  glands  situated  in  the  mucous 
membrane  enveloping  the  necks  of  the  organs.  Again,  in  mouths 
abounding  in  parasites,  microscopic  analysis  shows  plainly  enough 
the  analogy  with  the  coral  reef.  Hence  it  is  that  analyses  of  this 
supposed  common  material  are  found  so  markedly  and  decidedly  to 
differ. 

The  treatment  of  the  ordinary  collections  of  tartar  about  the  teeth 
is  very  simple,  and  may  be  made  very  effectual.  Various  cutting 
and  scraping  instruments,  very  well  understood  by  glancing  at  the 
engravings.  Fig.  214,  are  used  in  the  process  of  removal.  The 
operation  consists  simply  in  scraping  away  the  mass  (scaling,  it  is 
termed),  being  careful  not  to  scratch  the  enamel,  and  afterward 
thoroughly  polishing  the  teeth, — using  for  the  purpose,  first,  pul- 
verized pumice,  afterward  the  ordinary  burnishing  instruments. 


Fig.  214. — Instruments  employed  in  removing  Tartar  from  Teeth. 


To  prevent  re-collection,  cleanliness  is  a  first  requirement :  the 
use  of  acid  washes,  carbolic  acid  soap,  or  dentifrices,  is  to  be  directed, 
as  may  seem  to  the  judgment  of  the  practitioner  indicated,  and  the 
action  of  the  glands  is  to  be  increased,  by  the  use  either  of  local  or 
constitutional  sialagogues.  Or,  if  in  any  individual  case  the  ad- 
visability of  such  prescriptions  might  seem  debatable,  then  pumice- 
stone,  finely  pulverized,  may  be  used  with  a  good  stiff  brush ;  or, 
what  will  be  found  a  still  better  plan,  the  patient  may,  every  few 
days,  standing  before  a  mirror,  use  the  grit  on  a  piece  of  soft  pine 
or  orange  stick. 

Salivary  calculus,  lodged  about  the  teeth,  has  been  thought  to  pro- 
duce caries  and  necrosis  of  the  alveolar  processes.  I  do  not,  however, 
remember  in  my  own  practice  ever  to  have  seen  such  a  result.     As 


504  ORAL  DISEASES  AND   SURGERY. 

the  teeth  drop  out,  the  calculus  falls  away  with  them,  and  thus  its 
power  for  evil  ends.  A  spongy  and  scorbutic  character  of  gum 
tissue,  and  consequent  hemorrhage,  are,  however,  very  common 
associations  ;  but  the  practitioner  at  once  sees  that  the  cure  is  in 
his  own  hands. 

The  use  of  acids,  highly  commended  by  some  as  a  conclusion  to 
the  operation  of  scaling,  is  by  no  means  an  objectionable  practice. 
Not  only  does  an  acid,  judiciously  applied,  cleanse  the  teeth  thor- 
oughly, but  it  also  destroys  infusoria  which  are  themselves,  as  we 
have  seen,  tartar;  and  it  serves  as  a  stimulus  to  the  deteriorated 
and  generally  spongy  neighboring  soft  parts.  Of  acids  which  may 
be  used  for  this  purpose,  none  have  advantage  over  the  aromatic 
sulphuric,  this  being  employed  pure  or  diluted,  according  to  the 
nature  of  the  teeth  to  which  it  is  applied,  and  the  work  proposed  to 
be  done  with  it.  Acid  is  most  conveniently  used  from  the  end  of  a 
pine  stick,  the  detritus  left  by  the  scaler  being  softened  and  dissolved 
by  it,  and  ulterior  ill  effects  neutralized  by  frequent  rinsing  with 
ammoniated  water.  The  objection  that  an  acid  will  dissolve  the  lime 
salts  of  the  teeth,  as  well  as  the  offense  against  which-it  is  directed, 
has  as  little  weight  as  that  a  scaler  will  cut  enamel,  or  that  calomel 
will  salivate. 


CHAPTER    XXIII. 

DENUDATION. 

This  affection,  at  once  appreciated  by  referring  to  the  drawings, 
is,  witliout  doubt,  one  of  the  most  deforming  conditions  to  which  the 
dental  organs  are  subject.  It  is  sometimes  seen  attacking  every 
individual  tooth  ;  at  others,  confining  its  ravages  to  a  very  few.  A 
very  common  seat  of  the  affection  is  where  the  gum  festoons.  Here 
may  be  seen  a  sulcus  or  groove  passing  from  tooth  to  tooth,  involv- 
ing all  those  situated  in  the  anterior  part  of  the  arch.  Another 
form  of  the  affection  involves  the  cutting  edges  alone  ;  while  in  still 
other  cases  the  depressions  are  situated  promiscuously  over  every 
portion  of  the  teeth. 

The  disease,  commencing  as  a  slight  gutter  or  break  in  the 
enamel,  progresses  with  a  varying  degree  of  rapidity,  sometimes 

Figs.  215  and  216. — Dekcdation. 


moving  with  such  slow  pace  as  scarcely  to  be  observed  from  year  to 
year ;  in  other  instances,  and  these,  unfortunately,  much  the  most 
frequent,  making  constant  attention  necessary  to  the  preservation  of 
the  organs.  Occasionally  the  process  begins  at  a  number  of  points, 
and  these,  enlarging,  finally  coalesce,  to  the  destruction  not  unfre- 
quently  of  all  the  anterior  enamel  wall. 

Concerning  the  cause  or  causes  inducing  this  condition,  much 
diversity  of  opinion  exists.  The  present  conviction  of  the  author  is 
that  the  true  explanation  is  just  now,  for  the  first  time,  enunciated 
in  the  electro-chemical  experiments  made  by  Mr.  Kencely  Bridgraan 
(see  Dental  Caries),  and  that  in  this  direction  will  be  found  to  lie 
not  alone  the  cause,  but  the  prophylaxis.  As  all  that  may  be  said  on 
this  subject  is  expressed  in  the  experiments  themselves,  the  careful 
attention  of  the  reader  is  directed  to  them.  True  it  would  seem  to 
be,  however,  that  back  of  the  immediately-acting  cause  must  lie  a 
predisposition:  here  would  seem  to  be  the  result  of  impressions  made 
on  the  enamel  at  the  period  of  its  formation,  and  which  deficiency 

(505) 


506  ORAL  DISEASES  AND  SURGERY. 

the  nutritive  functions  have  failed  to  correct.  It  might,  indeed,  verj 
well  be  that  such  enamel  is  entirely  deficient  in  vital  resistance,  and 
thus  subject  to  be  acted  on  as  any  inorganic  structure,  being  by 
electrolytic  action  simply  dissolved.  To  combat  such  a  condition, 
electrolysis  must  be  negated.  If  the  assumptions  from  the  experi- 
ments of  Mr.  Bridgman,  here  made,  and  which  seem  to  the  author 
so  rational,  be  accepted,  the  treatment  of  denudation  is  the  antag- 
onism of  electro-chemical  action  ;  this  perhaps  alone,  as  devitalized 
enamel  might  not  be  aided  by  vital  defense. 

Treatment  of  denudation  has  heretofore  been  confined  exclusively 
to  combating  by  operative  means  the  ravages  inflicted,  such  means 
consisting  in  reaming  out  and  filling  with  metal  the  cavities,  as  one 
after  another  may  threaten  from  its  extent  and  depth. 

Abrasion  of  the  cutting  face  of  the  teeth  from  mechanical  causes  is 
a  very  common  affection,  and  a  very  unfortunate  one.  The  articula- 
tion of  the  two  dentures  has  much  to  do  with  the  production  of  such  a 
condition  ;  indeed,  everything,  if  we  except  an  abnormal  softness 
of  enamel  as  found  in  certain  teeth.  Teeth  that  articulate  scissor- 
fashion,  the  one  set  over  or  in  front  of  the  other,  seldom  suffer  from 
this  trouble.     It  is  most  markedly  an  affliction  of  direct  articulation. 

Persons  having  jaws  thus  articulated  find  their  teeth  year  by  year 
wearing  shorter;  and  were  it  not  that,  as  this  abrasion  goes  on, 
nature  offsets  the  waste  by  internal  repairs,  throwing  out  layer  after 
layer  of  secondary  dentine,  the  dental  pulps  would  be  quickly  enough 
exposed. 

The  character  of  food  used,  while  perhaps  it  would  never  yield 
this  condition,  yet,  the  predisposition  in  the  articulation  existing, 
without  doubt  assists  in  the  destruction.  Thus,  it  is  remarked  that 
sailors,  eating  constantly  of  hard  bread,  and  chewers  of  tobacco,  are 
most  subject  to  abrasion.  This  is  strictly  true,  however,  only  as  it 
applies  to  such  as  have  the  peculiarity  of  articulation,  and  with  such 
the  progress  of  abrasion  is  commonly  very  rapid. 

A  means  of  relief  to  this  condition  which,  while  fairly  successful, 
is  associated  with  more  or  less  discomfort,  consists  in  the  adaptation 
to  the  posterior  teeth  of  caps  of  metal.  These  caps  take  the  strain 
of  mastication,  and  thus  protect  the  teeth.  Another  mode,  but 
which  is  apt  to  excite  inflammation,  consists  in  cutting  out  cavities 
from  the  abrading  faces  of  the  teeth,  and  supplying  the  place  of  the 
removed  dentine  with  plugs  of  gold.  This  latter  plan  has  many 
advocates,  and  is  highly  commended  by  practitioners  of  experience 
and  judgment. 


( 


CHAPTER    XXI  y. 


SALIVARY    FISTULA. 


By  a  salivary  fistule  is  meant  a  break  in  the  continnity  of  structure, 
either  of  a  salivary  gland  itself  or  its  tube  of  outlet,  through  which 
break  the  secretion  is  poured  over  external  parts  rather  than  passing 
into  the  mouth  to  fulfill  its  recrementitial  offices. 

The  causes  of  salivary  fistulas  are  various.  In  children,  cancrum 
oris  has  frequently  so  sloughed  away  portions  of  the  cheek  as  to 
produce  the  most  intractable  sinuses,  necessitating,  indeed,  plastic 
operations  for  their  cure. 

Wounds  of  lacerated  character,  and  burns,  are  other  causes  of  such 
fistulae.  Abscesses,  osseous  and  dental,  venting  througli  the  cheek 
and  involving  in  their  course  the  Stenonian  duct,  are  causes  with 
which  the  author  has  several  times  met.  Epithelial  cancers  eroding 
the  cheek  are  conditions  encountered.  Salivation,  once  a  most 
common  cause,  is  fortunately  now  seldom  met  with.  Surgical 
operations  exposing  the  glands  or  ducts  are  to  be  enumerated  as 
causes. 

A  rare  cause  of  salivary  fistulae  met  with  by  the  author  on  two 
different  occasions,  the  diagnoses  of  which  have  been  verified  by 
removal  of  the  organ,  consists  in  an  apparent  subcutaneous  ulcer- 
ation of  several  lobules  of  the  gland,  the  secretion  being  thus  in 
small  quantity  continuously  discharged  and  forming  hydrocele.  In 
one  of  these  instances — to  be  detailed — an  adventitious  sinus  led  the 
secretion  from  the  sublingual  gland  to  the  supra-hyoid  bursa,  forming 
a  cyst  as  large  as  the  fist. 

The  principle  of  the  treatment  of  salivary  fistule  is  found  in  re- 
storing by  any  capable  means  the  original  tube  of  passage. 

Fig.  21t  exhibits  a  fistule  upon  the  cheek,  the  break  being  into 
the  duct  of  Steno,  near  its  orifice.  On  the  same  diagram,  situated 
just  above  the  angle  of  the  jaw,  is  shown  a  second.  This  represents 
the  condition  as  connected  with  the  gland  proper. 

Fistulae  are  treated  by  cauterization  and  by  operation.  The  first 
manner  has  its  application^articularly  in  exposures  of  the  substance 

(507) 


508 


ORAL  DISEASES  AND   SURGERY. 


of  the  glands,  and  perhaps  in  most  of  such  instances  invites  to  a 
trial  which  shall  precede  operative  measures. 

Fig.  217. — Salivary   Fistule — from  Life. 


A  mode  of  cauterization,  which  has  the  commendation  of  several 
successful  cases  reported,  consists  in  pointing  a  stick  of  nitrate  of 
silver,  and  forcing  it  through  the  track  of  the  sinus  down  to  the 
gland.  When  a  sinus  is  straight,  and  the  caustic  may  thus  be  made 
to  reach  the  place  of  disease  in  the  organ,  the  practice  is  to  be  highly 
commended.  In  the  tortuous  track,  however,  such  a  means  may  not 
apply ;  the  track  may  be  closed,  but,  the  surface  of  secretion  being 
unobliterated,  the  accumulating  secretion  needs  but  a  very  short 
time  to  re-establish  the  track.  Fistul®  of  irregular  track  connected 
with  the  glands  are,  with  most  hope  of  success,  through  this  means 
treated  by  injection.  Such  injection  may  be  saturated  solutions,  if 
deemed  necessary,  and  may  be  either  of  the  nitrate  of  silver,  of 
chloride  of  zinc,  or  of  iodine. 

Of  the  operative  means  resorted  to  for  the  cure  of  salivary  fis- 
tulae  quite  a  variety  have  been  practiced.  A  common  operation,  and 
one  most  easily  performed,  applicable  particularly  to  breaks  in  the 
continuity  of  the  Stenonian  duct,  consists  in  taking  a  strand  of  well- 
waxed  ligature  silk,  threaded  at  each  end  to  straight  or  curved 
needles,  as  preferred.  Seeking  the  bottom  of  the  fistule,  the  first 
needle  is  thrust  through  the  cheek  into  the  vestibule,  and  brought 
out  at  the  orifice  of  the  mouth  ;  the  second  needle  is  now  passed  to 
the  bottom  of  the  fistule  precisely  as  the  first,  and  is  also  thrust 
through  into  the  vestibule,  but  leaving  some  little  tissue  between  its 


SALIVARY  FISTULJS.  509 

exit  and  the  line  of  the  first.  The  two  ends  being  out  of  the  mouth, 
a  single  knot  is  made,  drawing  it  close  up  to  the  mucous  surface  of 
the  cheek,  strangulating  the  contained  tissue.  The  strangulation, 
however,  is  not  absolutely  necessary,  many  surgeons,  indeed,  pre- 
ferring the  knot  loose,  and  to  have  the  new  passage  resultant  simply 
from  the  presence  of  the  silk.  With  such  a  new  passage,  the  origi- 
nal fistule  will  frequently  tend  to  close.  Particularly  will  this  be 
found  the  case  where  the  new  passage  has  been  so  made  as  to  afford 
easier  exit  for  the  fluid  than  the  fistule. 

A  second  plan  of  operation  is  one  devised  by  the  late  Professor 
Horner,  of  the  University  of  Pennsylvania,  and  is  that  preferred 
and  practiced  by  many  surgeons.  Fig.  3,  Plate  VI.,  exhibits  this 
operation.  Employing  a  punch,  a.  simple  incision  is  first  made  from 
the  surface  of  the  cheek  down  to  the  line  and  position  of  the  duct: 
placing  now  against  the  mucoua  aspect  of  the  cheek  a  wooden 
spatula,  the  punch  is  directed  to  the  bottom  of  the  superficial  wound 
made  by  the  knife,  and  then  pushed  through  to  the  spatula,  thus,  as 
is  seen,  cutting  out  a  section  of  the  tissue,  and  affording  a  track  to 
the  discharge.  The  external  incision  is  closed,  and  attempt  made  to 
secure  immediate  union. 

As  a  study  in  a  class  of  cases  oftentimes  found  quite  defying,  the 
following  may  be  offered. 

The  patient,  a  gentleman  of  excellent  constitution  and  in  easy 
circumstances,  suffering  from  a  carious  wisdom-tooth,  had  sought 
relief  in  its  extraction.  The  dentist,  however,  had  the  misfortune 
to  break  the  tooth,  and  was  unable  to  remove  the  fang.  From  the 
resulting  irritation,  conjoined  with  that  residing  in  the  broken  and 
inflamed  root,  caries  of  the  bone  was  induced ;  this,  in  its  turn, 
inflaming  the  cheek,  an  abscess  formed  ;  this  opened  externally, 
involving  in  its  passage  the  duct  of  Steno,  thus  producing  fistule. 
The  condition  of  the  patient  was  as  follows  :  the  natural  outlet  of 
the  gland  continued  patulous;  consequently,  to  the  comfort  of  the 
case,  much  of  the  secretion  found  its  way  into  the  mouth.  Through 
the  artificial  channel  enough,  however,  escaped  to  keep  the  cheek, 
constantly  bathed  with  saliva  and  pug,  the  orifice  being  continuously 
covered  with  a  large,  but  soft  and  pasty,  imperfect  scab.  Of  course, 
so  long  as  the  saliva  discharged  through  this  channel,  it  was  im- 
possible for  nature  to  close  it. 

In  this  case, — which  had  been  under  the  treatment  of  different 
persons  for  over  two  years, — three  weeks,  lacking  three  days,  were 
required  for  the  cure.    First,  examination  was  directed  to  the  condi- 


510  ORAL  DISEASES  AND   SURGERY. 

tion  of  the  underlying  parts.  The  caries  of  the  bone  being  found 
cured,  the  depth  and  course  of  the  fistuie  were  discovered  by  the  use 
of  the  ordinary  silver  probe.  This,  for  three  days,  was  enlarged  by 
the  introduction,  each  day,  of  a  twisted  tent  of  cotton.  At  the  end 
of  this  period  a  slender,  straight-bladed  bistoury  was  passed  directly 
through  the  cheek  into  the  mouth.  An  eyed  probe  was  next 
threaded  with  a  cotton  tent,  large  and  thick  at  the  part  which  was 
to  occupy  the  inner  half  of  the  thickness  of  the  cheek,  delicate  and 
as  threadlike  as  it  could  be  made  where  it  was  to  be  lodged  in  the 
external  track  of  the  fistule.  By  the  aid  of  the  probe  this  tent  was 
carried  through  the  cheek,  and  was  then  fixed  in  position  by  a  little 
slip  of  adhesive  plaster,  attaching  it  to  the  cheek  This  tent,  being 
kept  clean  and  disinfected  by  daily  syringing,  was  retained  in  posi- 
tion one  week,  the  swelling  of  the  inner  bulk}^  portion  having  by  this 
time  resulted  in  the  formation  of  quite  a  channel,  with  a  correspond- 
ing diminution  in  the  diameter  of  the  fistule.  At  this  stage  the 
cotton  was  replaced  with  a  wire  seton,  made  by  taking  the  most 
delicate  of  ligature  iron  wire,  and  doubling  it  upon  itself  a  number  of 
times  to  half  the  thickness  of  the  cheek,  a  single  strand  continuing 
the  length  designed  to  occupy  the  line  of  the  fistule.  To  replace  the 
one  with  the  other  it  w'as  only  necessary  to  attach  them  by  an  in- 
termediate strand  of  silk:  as  one  was  withdrawn,  the  other  occu- 
pied its  place.  This  wire  seton  was  thus  inserted,  and  was  held 
in  place  by  perforated  shots  clamped  on  each  extremity.  In  one 
week  the  external  or  original  fistule  had  closed  so  as  to  hug  the 
wire,  the  discharge  being  entirely  into  the  mouth.  The  seton  was 
now  withdrawn  entirely,  and  on  the  next  day  complete  closure  was 
found  to  have  resulted.  The  case  was  thus  dismissed  cured,  and 
has  remained  so. 

A  fistule  of  the  parotid  gland  proper,  failing  to  close  upon  cauteri- 
zation, may  be  treated  precisely  as  the  case  just  detailed.  In  place, 
however,  of  the  pyramidal  coil,  a  rope  of  wire  is  to  be  used,  three 
or  more  strands  being  twisted  together ;  the  track  leading  to  the 
mouth  is  to  be  the  shortest  that  may  be  selected. 

Fig.  218  represents  a  case  and  operation  having  the  following 
history:  it  will  be  seen,  however,  to  come  as  properly  under  the  head 
of  ranula  as  of  fistula.  The  drawing  is  from  a  photograph  taken  at 
the  time  of  the  operation. 

First  it  was  noticed  by  the  patient  that  the  parts  beneath  the 
chin  began  to  soften  and  grow  broad,  freedom  of  motion  was  lost 
in  the  jaw,  and   a  slight   sense   of  difiSculty  was   experienced  in 


SALIVARY  FISTULA. 


511 


speech,  as  the  result  of  stiffness  about  the  tongue,  the  floor  of  the 
mouth  being  quite  indurated.    In  the  course  of  four  months,  a  tumor, 


Fig.  218. 


evidently  cystic,  and  fully  the  size  of  an  ordinary  orange,  occupied 
the  front  of  the  neck,  but  happily  concealed  by  the  long  and  heavy 
beard  of  the  patient. 

Presenting  himself  for  a  cure,  a  diagnosis  as  to  the  general  nature 
of  the  tumor  was  secured  through  the  aid  of  an  exploring-needle  ; 
this  valuable  instrument  demonstrating  not  only  that  the  tumefac- 
tion was  cystiform,  but  affording  an  idea  of  the  contents. 

Treating  the  tumor  as  a  cyst  of  an  immediate  signification,  as  a 
hydrocele,  a  bistoury  making  a  reasonable  incision  was  passed  into 
the  most  pendent  part;  the  contents,  a  mass  of  lymph-like  fluid, 
filling  a  large  goblet,  issued  as  a  continuous  rope;  in  color  and  con- 
sistence it  might  have  been  likened  to  thin  calves-foot  jelly.  The 
cavity  having  been  thoroughly  washed  with  warm  alum-water, 
compresses  were  carefulh^  adjusted  to  the  parts  and  sustained  by 
the  author's  strip  bandage.  In  two  weeks,  and  without  any 
trouble,  the  parts  had  united,  and  the  cyst  seemed  permanently 
obliterated. 

One  month  later  the  patient  again  presented  himself  The  tumor 
was  re-forming :  the  cyst  apparently  had  not  been  obliterated ; 
already  it  was  the  size  of  a  walnut.  A  few  days  later  a  second 
operation  was  performed  precisely  as  in  the  first  instance  ;  the  con- 
tents of  the  cyst  differed,  however,  at  least  in  color,  having  the  same 
colloid  consistence,  but  being  blood-red.    After  the  incision,  and  after 


512  ORAL   DISEASES  AND  SURGERY. 

evacuating  the  cavity,  determined  on  obliterating  the  cyst,  I  syringed 
it  with  the  officinal  tincture  of  iodine,  undiluted,  stuflBng  the  cyst 
afterward  loosely  with  cotton.  I  this  time  succeeded  in  producing 
a  perfect  cure  ;  but  the  swelling,  associated  with  the  inflammation 
produced  by  the  injection,  was  so  great  that  it  was  only  with  the  aid 
of  leeches,  and  cathartic  and  diaphoretic  medicines,  combined  with 
the  closest  attention,  extending  over  four  days,  that  I  succeeded  in 
preserving  the  man's  life :  for  two  whole  days  the  patient  was  unable 
to  swallow  even  teaspoonful  measures  of  water,  and  breathed  with 
the  greatest  difficulty. 

What  was  this  tumor?  Evidently  a  hydro-hematocele,  the  start- 
ing-point of  the  lesion  being,  I  think,  in  a  sublingual  gland.  It 
might  be  suggested  that,  had  it  belonged  to  this  gland,  the  swelling 
would  have  exhibited  itself  more  in  the  mouth.  My  reason  for 
inferring  that  it  was  so  associated  lay  in  the  fact  that  a  blunt  probe 
passed  into  the  cavity  could  readily  be  felt  in  the  position  of  the 
left  of  these  bodies,  in  the  mouth. 

!|6  3|C  JJC  5^  ^  ^  ijC 

The  preceding  history  of  this  case  is  one  of  the  illustrations 
offered  in  the  chapter  on  Ranula,  published  in  "'  Diseases  and  Sur- 
gery of  the  Mouth,  Jaws,  and  Associate  Parts  :"  it  was  written 
four  months  after  every  evidence  existed  as  to  the  completeness  of 
a  cure. 

As  a  coincidence,  it  occurred  that,  on  the  very  day  on  which  the 
perfected  proofs  of  the  chapter  were  put  into  my  hands  (the  form 
being  struck  off),  this  patient  again  presented  himself,  the  neck 
exhibiting  every  evidence  of  a  return  of  the  tumor. 

I  now  determined  on  and  practiced  an  operation  which  exposes 
the  case  in  its  most  instructive  light. 

As  illustrated  in  the  diagram,  a  crucial  incision  was  made,  ex- 
posing, in  the  retraction  of  the  flaps,  the  common  deep  fascia  of  the 
neck,  which  fascia  constituted  the  floor  of  the  cyst,  and  was,  in 
appearance  and  consistence,  apparently  natural. 

Passing  into  a  sinus  in  this  deep  fascia,  and  emerging  from  the 
mouth,  the  reader  observes  the  probe.  The  orifice  of  this  sinus 
was  very  small,  and  was  only  seen  after  the  parts  had  been  thor- 
oughly cleansed  ;  the  track  was  exceedingly  tortuous,  and  was  not 
passed  until  after  several  attempts,  and  only  at  last  by  the  experi- 
mental bending  of  the  probe. 

On  reaching  the  floor  of  the  mouth,  it  was  evident  enough  that 
the  instrument  struck  the  sublingual  gland,  as  without  effort  this 


SALIVARY  FISTULA.  513 

body  could  be  thrust  upward  from  its  bed.  To  thus  elevate  and 
dissect  out  the  organ,  which  was  done,  was  a  matter  of  no  difficulty. 
To  complete  the  operation,  the  walls  of  the  cyst  were  slightly 
cauterized  with  the  solid  stick  of  nitrate  of  silver,  and  the  flaps  laid 
in  place,  and  secured  with  the  necessary  stitches  of  interrupted  su- 
ture; adhesion  was  secured  by  compresses  continued  over  a  month. 
Examination  of  the  resected  gland  discovered  upon  its  under 
surface  a  break  in  its  continuity,  evidently  pathological  and  of  long 
standing ;  thus  was  demonstrated  the  ranulous  character  of  the 
tumor.  Little  by  little  the  salivary  secretion  had  worked  this 
passage  downward,  securing,  by  its  slow  progress,  an  adventitious 
tissue,  or  walled  sinus. 

Looked  at  from  the  cervical  base,  one  would  naturally  have 
viewed  the  sinus  as  being  made  by  a  prolongation  of  the  fascia,  so 
precisely  did  it  look  as  though  a  tubular  cul-de-sac  had  elongated 
itself  until  it  had  met  and  associated  itself  with  the  base  of  the 
gland. 

The  question  of  the  location  of  this  tumor  is  not  without  a  special 
interest. 

Does  it  prove  the  existence  of  a  supra-hyoid  bursa,  described  by 
some  anatomists  and  searched  for  in  vain  by  many  others  ?  If  such 
bursa  had  not,  in  this  particular  case  at  least,  an  existence,  how 
shall  we  as  naturally  explain  the  presence  of  the  perfect  cyst  which 
formed  the  tumor  ? 

A  second  point  of  interest  lies  in  the  fact  of  the  reaching  of  the 
gland  described  in  the  first  diagnosis  made  months  before.  This,  it 
would  seem,  could  only  have  been  the  result  of  a  rare  accident, 
which  on  that  occasion  directed  the  probe  into  the  sinus,  and  gave 
to  the  parts  that  favorable  position  which  made  the  passage  a  direct 
one. 

This  case,  viewed  from  the  standpoint  of  fistula,  is  one  of  great 
interest  and  instructiveness :  had  the  tumor  been  allowed  to  en- 
large and  attenuate  the  walls,  and  thus  to  rupture,  it  is  evident  that 
the  case  would  have  been  one  of  salivary  fistula  proper. 

As  another  illustration,  tlie  following  case  may  be  given: 

Mr.  ,  an  old  gentleman,  had  upon   his  right  cheek  an  ulcer 

the  size  of  a  dime-piece.  This  sore,  subjected  to  a  great  variety  of 
treatment  at  diflerent  hands,  obstinately  refused  to  heal,  yet  did  not 
grow  worse.  Decided  to  be  epithelioma,  it  was  finally  let  alone, 
mild  dressing  being  employed  simply  as  a  protection. 

Carefully  absorbing  from  the  face  of  this  ulcer  the  moisture  and 

33 


514  ORAL  DISEASES  AND  SUBGERY. 

pus  with  which  it  was  alwaj^s  covered,  having  at  the  time  the  eve 
upon  the  sore,  it  could  be  noticed  that  almost  immediately  the  part 
became  remoistened  by  a  watery  film.  This  leading  to  the  inference 
of  an  association  with  the  salivary  duct,  search  was  made,  through 
the  agency  of  a  niagnifying-glass,  for  any  expression  of  communi- 
cation which  might  exist, — a  sinus  of  most  minute  calibre  being 
discovered.  Here  at  once  was  the  signification  of  the  ulcer.  A  cure 
was  quickly  effected  by  the  employment  of  the  thread  seton. 

Still  another  character  of  cases  is  found,  where,  from  the  existence 
of  a  minute  break  in  the  continuity  of  the  Stenonian  duct,  the  nat- 
ural outlet  being  normal,  a  cystic  form  of  tumor  of  most  indolent 
character  is  found  in  the  substance  of  the  cheek.  I  have  met  with 
several  of  these  cases,  and  at  first  was  entirely  deceived,  making 
matters  worse  by  opening  them.  The  diagnosis  is  found  in  the  ex- 
ercise of  a  patient  manipulation,  which  may  empty  the  cyst,  forcing 
the  saliva  back  into  the  duct.  Compression,  with  stimulation,  is  the 
principle  of  cure.  If  opened  by  mistake,  they  are  to  be  treated  like 
any  other  form  of  the  condition. 

A  condition  somewhat  the  reverse  of  the  last,  being  one  of  most 
simple  signification  and  diagnosis,  is  occasionally  to  be  met  with, 
where,  from  some  active  cause  of  obstruction  about  the  tube  of 
Steno,  a  tumor  of  rapid  formation  is  found  along  the  line  of  the  duct. 
This  is  simply  a  species  of  ranula,  but,  if  untreated,  may  form  a 
fistula  by  ulcerating  externally.  To  combat  successfully  such  a  con- 
dition, it  is  desirable  to  enlarge  or  render  patulous  the  natural  outlet 
by  insinuating  into  the  canal  a  threaded  probe.  This,  being  carried 
into  the  tumor,  is  incised  upon.  Through  an  opening  thus  made, 
the  probe,  followed  by  its  thread,  is  to  be  withdrawn  ;  the  interme- 
diate line — being  that  of  the  stricture — is  now  included  in  a  loop, 
which  is  to  be  left  to  take  care  of  itself. 

Having  treated  many  cases  of  salivary  fistula,  anomalies  of  vari- 
ous significance  and  interest  have  no  doubt  been  met  with  by  the 
author,  which  do  not  at  present  recall  themselves.  The  principle  of 
treatment  for  every  form  and  variety  may  only,  however,  be  a  com- 
mon one. 


PLATE    VI. 

A  VIEW  OF   THE  ANATOMY  OF    THE    SIDE    OP   THE    FACE,  AND    OF    SOME 
OF    THE    OPERATIONS   PRACTICED    ON    IT. 

Fig.  1. — A  side  view  of  the  Anatomy  of  the  Face  after  the  removal  of  the 
integuments.  1.  The  shape  and  position  of  the  parotid  gland.  2. 
The  duct  of  Steno.  3.  The  sublingual  gland.  4.  The  facial  artery, 
at  the  point  where  it  passes  on  to  the  face.  5.  The  facial  vein.  6. 
The  sterno-cleido-mastoid  muscle.  7.  The  external  jugular  vein. 
8.  The  zygomatic  muscle.  9.  Branches  of  the  portio  dura  nerve 
emerging  from  the  upper  edge  of  the  parotid  ;  other  branches  are 
seen  on  the  face. — After  Barnard  and  Huette. 

Fig.  2. — The  same  Section  after  the  removal  of  the  Parotid  Gland.  1.  The 
portio  dura  nerve  at  its  exit  from  the  stylo-mastoid  foramen.  2. 
The  duct  of  Steno  divided  transversely.  3.  The  external  carotid 
artery  when  freed  from  the  parotid.  4.  The  temporal  artery.  5. 
The  facial  artery  after  removal  of  the  sublingual  gland.  6.  The 
sterno-cleido  muscle.  7.  Main  trunk  of  the  external  jugular 
vein. — After  Bernard  and  Huette. 

Fig.  3. — A  three-quarter  view  of  Horner's  operation  for  the  cure  of  Salivary 
Fistula.  A  wooden  spatula  supports  the  inside  of  the  cheek ;  a 
slight  longitudinal  incision  is  made  at  the  external  fistulous  orifice, 
and  the  hand  of  the  surgeon  is  seen  pressing  the  punch  against  the 
spatula  so  as  to  cut  out  a  piece  through  the  cheek.  The  external 
incision,  being  closed  by  a  point  of  a  suture,  heals  usually  by  the 
first  intention,  leaving  the  orifice,  made  by  the  punch,  open  in  the 
mouth. — Drawn  from  Nature. 

Fig.  4. — A  view  of  the  operation  of  Resection  of  the  Upper  Jaw,  as  practiced 
by  the  incision  of  Warren.  1,  2,  3.  The  flaps  everted,  and  turned 
over  the  nose  and  eye  so  as  to  expose  the  bone.  The  left  hand  of 
the  surgeon  is  holding,  4,  the  bone  at  the  moment  of  disarticu- 
lation by  the  knife,  5,  which  is  working  at  the  pterygo-maxillary 
fissure.  Velpeau's  operation  is  nearly  the  same  as  that  of  War- 
ren.— After  Bernard  and  Huette. 

Fig.  5. — Eepresents  the  completion  of  the  operation,  the  union  of  the  wound 
by  the  twisted  suture,  and  the  line  of  the  cicatrix,  which  extends 
from  the  malar  bone  to  the  mouth  near,  but  not  at,  the  angle. — 
After  Bernard  and  Huette. 

Fig.  6. — A  view  of  the  termination  of  Gensoul's  operation,  showing  the  lines 
of  his  incision.  1,  2.  The  first  incision  across  the  tumor.  3,  4. 
The  second  incision.  1,  5.  The  third  incision,  forming  flaps,  which 
are  to  be  turned  up  and  down  upon  the  face.  The  sutures  are  seen 
as  placed  at  the  termination  of  the  operation. — After  Gensoxd. 

Note. — Figs.  4,  5,  and  6  refer  to  operations  considered  in  another  connection. 

(515) 


CHAPTER    XXV. 


THE   TONSIL   GLANDS. 


Fig.  219. 


The  tonsil  glands,  situated  on  either  side  of  the  fauces,  between 
the  half  arches,  are  readily  exposed  by  depressing  the  tongue  through 
the  instrumentality  of  any  convenient  means.  An  instrument  made 
especially  for  the  purpose,  called  a  "depressor,"  will  be  found  very 
well  adapted.* 

The  tonsils,  glandular  organs,  expressed 
by  Virchow  as  being  the  analogue  of  the 
lymphatic  glands,  are  made  up  of  many 
lobules,  congeries  of  mucous  follicles,  with 
intervening  sulci  lined  by  involutions  of  the 
common  mucous  membrane.  Inflanmiation, 
simple  or  acute,  and  chronic  or  morbid,  is  the 
disease  of  these  glands.  With  the  first  are 
associated  the  various  features  of  vascular 
change,  passing  from  the  most  transient  of 
congestions  to  the  most   threatening  of  ab- 

The  Tonsil  Glands.  SCCSSeS. 

Simple  tonsillitis — angina  tonsillaris — amygdalitis — is  an  inflam- 
mation of  the  substance  of  the  gland.  Looking  into  the  mouth,  the 
bodies,  one  or  both,  are  discovered  unduly  colored  and  swollen.  If 
the  inflammation  is  of  any  severity  in  its  grade,  the  patient  experi- 
ences pain  and  difficulty  in  swallowing,  with  a  sense  of  dryness, 
heat,  and  fever  in  the  fauces ;  and  these  discomforts,  influenced 
by  the  character  of  the  attack,  may  progress  until  it  becomes  im- 
possible to  swallow,  and  in  many  cases  exceedingly  difficult  to 
breathe. 

As  a  gargle,  found  most  reliable  in  such  cases, — or  rather  as  an 


*  It  is  a  singular  fact  that  depression  of  the  tongue  is  secured  by  simply 
laying  the  depressor  upon  it.  When  force  is  employed,  the  organ,  in  many 
cases,  spasmodically  resists,  crowding  against  the  roof  of  the  mouth. 


(516) 


THE   TONSIL    GLANDS.  517 

application  to  let  fall  and  hold  in  contact  with  the  parts,  for  the  act 
of  gargling  may  be  impossible, — the  following  may  be  employed  : 

R. — Plumbi  acetatis,  5j  5 
Tincturae  opii,  ^j ; 
Aquae,  §xij.     M. 

A  second  medicament,  highly  esteemed  by  many,  consists  in  a 
combination  of  tannin  and  glycerine,  the  application  being  made  to 
the  parts  with  a  brush. 

In  the  frequent  cases  in  which  the  congestion  is  associated  with' 
passivity,  resolution  will  be  found  oftentimes  quickly  effected  by  a 
gargle  compounded  as  follows  : 

R. — Sodse  biboratis,  Ji'j  ; 
Potassas  chloratis,  5j  ; 
Tincturae  capsici,  5'J5 
Tincturae  myrrhae,  §j ; 
Aquae,  ^viij.     M. 

Another  practice,  which  the  author  has  found  happily  applicable 
to  these  latter  conditions,  consists  in  first  brushing  the  parts  with  a 
solution  of  nitrate  of  silver,  four  grains  to  the  ounce  of  water,  and 
afterward  using  a  compound  iodine  and  carbolic  acid  gargle. 

R. — TincturaB  iodinii  compositae,  gtt.  xl  ; 
Acidi  carbolici  fluidi,  gtt.  vj ; 
Glycerinag,  ^j ; 
AquEe,  3vij.     M. 

Tincture  of  belladonna  has  lately  received  much  commendation 
as  a  remedy  in  acute  tonsillitis, — being  administered  in  from  two-  to 
fifteen-drop  doses,  repeated  every  two  hours  until  the  patient  is  re- 
lieved, or  until  contra-indicated,  either  as  great  dryness  in  the  throat 
is  induced,  or  as  the  pupil  exhibits  relaxation.  Local  applications 
are  also  highly  commended,  the  medicine,  it  being  affirmed,  having 
the  same  action  whether  applied  locally  or  given  internally, — that  is, 
diminishing  the  calibre  of  the  capillaries  by  its  action  on  the  vaso- 
motor system  of  nerves. 

Sympathetic  inflammation  of  the  tonsil  glands  is  not  infrequent. 
Among  the  most  common  of  such  relations,  and  where  a  treatment 
must  of  necessity  consider  the  influencing  lesion,  are  croup,  scarlet 
fever,  measles,  diphtheria,  typhoid  fever,  and  syphilis. 


518  ORAL  DISEASES  AND  SURGERY. 

Glancing  at  the  view,  which  exhibits  the  glands  in  a  state  of  par- 
tial enlargement,  it  is  plainly  enough  seen  that  the  isthmus  would 
be  closed  in  proportion  to  such  enlargement :  hence  the  difficulty 
experienced  in  deglutition  and  respiration.  Tonsillitis  ends  either 
in  resolution  or  suppuration. 

When  the  inflammation  is  met  with  in  its  incipiency,  attempts  are 
at  once  to  be  made  to  resolve  it  by  the  use  of  antiphlogistic  remedies. 
Free  scarification  has  occasionally  been  resorted  to  with  the  best 
results.  Leeches  externally  applied  between  the  angle  of  the  jaw 
^nd  the  sterno-cleido-mastoid  muscle, — to  be  emploved  only,  how- 
ever, in  the  vigorous  and  plethoric, — and  blisters,  directed  to  the 
nape  of  the  neck,  will  be  found  of  the  greatest  service.  Hot  foot- 
baths, continued  until  the  veins  of  the  legs  are  engorged,  or  until 
diaphoresis  results,  or  the  patient  grows  faint,  constitute  a  most 
satisfactory  and  reliable  means  of  relief.  If  the  inflammation  should 
have  advanced  to  a  point  in  which  the  system  at  large  sympathizes, 
as  exhibited  by  the  presence  of  fever,  hope  is  still  to  be  entertained 
of  recovery  by  resolution.  In  these  cases  I  have  found  it  good 
practice  to  place  the  patient  over  a  basin  of  steaming  water,  and, 
with  the  form  enveloped  up  to  the  very  mouth  in  blankets,  secure 
diaphoresis  by  a  plentiful  exhibition  of  the  spiritus  Mindereri — a 
tablespoonful  every  ten  minutes  until  the  desired  result  is  produced. 
This,  if  the  patient  is  robust,  may  be  succeeded  by  a  saline  cathartic. 
As  a  local  treatment,  it  will  be  found  very  agreeable  to  order  a 
lemonade,  made  by  crushing  ice  in  a  towel  or  napkin;  the  small 
particles  of  the  ice  thus  acidulated  may  be  taken  little  by  little  into 
the  mouth,  and  allowed  gradually  to  dissolve.  Another  application 
consists  in  a  gargle  of  flaxseed  tea,  in  which  is  dissolved  the  chlorate 
of  potash.  Tartar  emetic,  or  the  tincture  of  digitalis,  or  of  veratrum 
viride,  administered  internally,  is  of  much  use  in  controlling  the 
circulation.  A  very  useful  combination,  where  the  circulation  runs 
high  and  the  system  is  irritable,  is  as  follows : 

B. —  Liquoris  potassae  citratis,  §iij  ; 
Spiritus  aetheris  nitrosi,  3ss  ; 
Tincturae  veratri  viridis,  gtt.  xxv.     M. 
Sig. — From  5j  to  ^ss,  according  to  age  and  requirements. 

In  most  cases  of  tonsillitis  where  the  inflammation  is  excessive, 
the  uvula  will  be  found  to  participate  ;  swelling  occurring,  through 
serous  effusions,  not  unfrequently  to  such  an  extent  as  to  threaten 


THE   TONSIL   GLANDS.  519 

immediate  suffocation,  the  organ  dropping  into  the  chink  of  the 
glottis.  In  these  cases  it  may  be  proper  first  to  try  an  application 
of  the  tincture  of  iodine;  but  should  this  fail, — which,  in  the  ex- 
perience of  the  author,  will  be  found  most  likely, — immediate  resort 
is  to  be  had  to  section  of  the  mucous  sac  holding  the  effusion ;  such 
a  cut  will  quickly  cause  the  swelling  to  disappear.  Circumstances 
sometimes  arise  where  an  opening  into  the  larynx  or  the  trachea 
affords  the  only  chance  to  a  patient  for  his  life. 

Where,  in  defiance  of  all  treatment,  a  tonsillitis,  whatever  its  sig- 
nification, determines  toward  suppuration,  the  best  that  can  be  done 
is  to  hasten  the  process  as  rapidly  as  possible,  providing,  always, 
that  the  attendant  swelling  is  not  formidably  extensive.  In  these 
latter  cases  nothing  better  can  be  done  than  to  make  premature  in- 
cisions. Where  the  swelling  is  not  extensive  or  threatening,  gargles 
of  flaxseed  tea  will  be  found  both  soothing  and  encouraging  to  the 
formation  of  pus,  and  may  be  used  with  all  freedom. 

Where  pus  has  formed  in  a  gland,  it  is  a  proper  practice  to  void 
it  with  the  knife  as  soon  as  recognized.  This  may  be  done  with 
most  safety,  perhaps,  by  using  an  ordinary  tenotome,  or,  as  has  been 
recommended,  by  a  gum  lancet. 

In  inflammation  of  the  tonsil  glands  occurring  in  the  weak  and 
depressed,  the  abstraction  of  blood  is  never  perhaps  advisable  ;  too 
much  care  cannot  be  exercised  in  this  direction. 

Hypertrophy,  or  chronic  enlargement,  of  the  tonsils,  is  a  condition 
most  common  to  scrofulous  children,  and  pertains,  consequently,  to 
early  life,  being,  indeed,  very  rare  after  puberty,  and  never  perhaps 
seen  in  old  age  :  of  the  various  patients  upon  whom  I  have  operated 
for  the  relief  of  this  affection,  there  have  been  but  four  over  thirteen 
years  of  age.  The  enlarged  or  hypertrophied  tonsil  differs  very  much 
in  consistence  and  character  in  different  cases,  being  in  one  patient 
indurated  and  smooth,  in  another  spongy  and  lobulated.  In  color  an 
equal  variety  is  presented,  varying  in  appearance  from  the  scarlet  of 
an  arterial  injection  to  the  dull  blue  of  a  passive  venous  stagnation. 
One  of  the  inconveniences  associated  with  enlarged  tonsils  is  the 
effort  required  in  respiration,  particularly  during  sleep,  such  effort 
in  many  cases  being  really  painful  to  witness.  Another  is  the 
interference  with  hearing,  pressure  upon  the  Eustachian  tube  fre- 
quently occluding  this  passage,  particularly  when  the  patient  takes 
cold.  Speech  is  interfered  with  :  to  sing  softly  and  finely  with  the 
tonsils  enlarged  is  impossible. 


520  ORAL  DISEASES  AND   SURGERY. 

Tonsillar  hypertrophy  being  a  systemic  expression  rather  than  a 
strictly  local  disease,  very  little  true  benefit  has  been  derived  from 
the  employment  of  the  great  variety  of  direct 
remedies  which  from  time  to  time  have  been 
recommended.  A  patient  so  afflicted  is  to  be 
treated  from  the  constitutional  standpoint;  and 
to  this  end  nothing  in  my  experience  has  been 
more  conducive  to  good  than  cold  salt-water 
bathing:  indeed,  I  am  of  opinion  that,  as  a 
rule,  more  attention  will  be  found  required  to 

Hypertiophiod  Tonsil.  _  * 

the  direction  of  diet,  clothing,  exercise,  and 
general  mode  of  life  than  to  the  administration  of  medicine.  Where, 
however,  medication  seems  demanded,  it  is  to  be  directed  to  the 
correction  of  any  observable  constitutional  defect  or  irregularity. 
Iodine  and  its  preparations  are  not  always,  by  any  means,  indi- 
cated; and  not  unfrequently,  from  their  exhibition,  by  a  further 
debasement  of  the  vital  powers,  much  more  harm  than  good  has 
resulted.  It  does  not  seem  possible  to  lay  down  rules  that  shall 
apply  to  the  constitutional  treatment  of  such  cases,  except  so  far  as 
to  suggest  attention  to  all  the  functions  and  the  general  tonic  medi- 
cation mostly,  if  not  always,  demanded. 

Among  medicines  professed  to  be  possessed  of  specific  significa- 
tion, used  for  enlarged  tonsils,  sulphate  of  polassa  holds  the  most 
prominent  position.  This  preparation,  given  in  doses  of  from  five 
to  fifteen  grains,  continued  for  a  month  or  six  weeks,  will,  without 
doubt,  in  many  cases,  cause  the  hypertrophy  to  disappear.  It  is 
usual  to  combine  with  it  rhubarb  and  some  of  the  aromatics,  suffi- 
cient to  insure  mere  laxity  of  the  bowels. 

Where  enlargement  of  the  tonsils  associates  with  the  rheumatic  or 
gouty  diathesis,  colchicum  has  been  highly  commended  :  to  be  taken 
internally,  and  applied  externally  as  a  liniment  in  combination  with 
the  linimentum  saponis.  The  use  of  colchicum  in  such  direction  was 
originally  introduced  into  English  practice  by  a  Mr.  Harvey,  he  being 
led  to  his  conclusions  by  observing  the  relationship  of  the  contents 
of  the  tonsillar  follicles  with  the  concretions  found  in  the  joints  of 
the  rheumatic  and  gouty.* 

*  Foul  breath,  so  frequently  associated  with  the  soft  variety  of  tonsillar 
hypertrophy,  arises  from  the  degeneration  of  the  sebaceous  secretion  retained 
within  the  crypts,  and  from  the  inspissated  mucus  enveloping  the  glands.  The 
phenate  of  soda,  chlorine-water,  or  a  solution  of  the  permanganate  of  potash, 
either  of  these  being  combined  with  the  compound  tincture  of  capsicum,  will 
be  found  satisfactory  for  the  purpose  of  temporary  relief. 


THE    TONSIL    GLANDS.  521 

Another  remedy,  having  the  commendation  which  associates  with 
frequent  successful  response,  and  particularly  applicable  where  the 
condition  is  coincident  with  scarlatina,  is  found  in  the  acetate  of 
zinc:  it  is  prescribed  from  9j  to  5j  in  from  .^vj  to  o^'i'j  t)f  water 
and  glycerine,  given  in  tablespoonful  doses  every  four  hours,  or  in 
the  acute,  severe  cases,  oftener.  It  is  well  to  retain  it  for  a  moment 
in  contact  with  the  tonsils  before  swallowing. 

The  local  treatment  of  hypertrophied  tonsil  glands  resolves  itself 
into  the  threefold  direction  of  the  use  of  alteratives,  destruction 
by  cauterization,  and  amputation.  Of  the  first  of  these  means,  the 
iodide  of  zinc  holds,  perhaps,  the  most  prominent  position.  It  is 
used  in  solution  of  from  ten  to  thirty  grains,  being  applied  with 
a  brush  two  or  three  times  in  the  twenty-four  hours  ;  or,  as  the 
treatment  advances,  it  may  be  applied  pure,  as  it  deliquesces  when 
exposed  to  the  atmosphere. 

Pressure  by  the  finger,  frequently  repeated,  punctures  with  the 
point  of  a  bistoury,  gargles  of  capsicum, — means  of  such  character 
may  be  tried,  as  judgment  shall  make  preference  for  one  or  the  other. 
It  is  to  be  regretted,  however,  that  the  promise  by  such  mode  of 
treatment  is  not  the  most  satisfactory ;  and  it  is  always  to  be  borne 
in  mind  that  if  such  agents  are  found  to  do  good  even  by  controlling 
the  enlargement,  it  may  be  prudent  to  rest  satisfied,  as  advancing 
age  will  generally  be  found  to  afford  correction  to  the  trouble. 

The  second  mode  of  treatment — that  by  cauterant  destruction — 
may  be  said  to  have  been  made  most  practical  by  A.  Ruppaner, 
M.D.,  of  New  York.  A  practice  introduced  by  this  gentleman,  and 
whose  successes  have  been  verified  in  quite  a  number  of  cases  by 
the  author  in  his  own  practice,  consists  in  the  use  of  the  London 
paste  recommended  by  Dr.  Morrell  Mackenzie.  The  following  are 
the  directions  for  the  preparation  and  use  of  this  paste : 

"A  quantity  of  equal  parts  of  finely-pulverized  and  well-mixed 
caustic  soda  and  xinslacked  lime  is  kept  on  hand.  When  an  appli- 
cation is  to  be  made  to  the  tonsils,  a  little  of  the  powder  is  put  into 
a  small  porcelain  cup  ;  a  few  drops  of  absolute  alcohol,  which  is 
kept  near  at  hand,  are  added  ;  the  two  are  carefully  mixed  with  a 
glass  rod,  when  the  paste  is  ready  for  use.  Care  must,  however,  be 
taken  that  it  be  of  the  proper  consistency.  If  too  thin,  it  is  apt  to 
find  its  way  to  parts  which  ought  not  to  be  touched;  if  too  thick 
or  lumpy,  the  paste  will  not  readily  stick,  and  little  pieces  might 
be  swallowed.  To  apply  the  paste,  a  glass  rod  of  sufficient  length 
ought  to  be  used.  One  end  of  it,  which  must  be  smooth  and  slightly 


522  ORAL  DISEASES  AND  SURGERY. 

funnel-shape,  is  dipped  into  the  paste,  and  a  greater  or  lesser  portion 
of  the  surface  touched,  as  occasion  may  require. 

"  To  apply  the  paste,  the  patient  should  be  placed  in  the  position 
for  laryngoscopy.  The  tongue  is  then  to  .be  depressed  with  the 
spatula,  and  the  paste  applied  to  the  enlarged  surface  for  two  or 
three  seconds.  The  action  of  the  escharotic  upon  the  tonsil  is  rapid. 
The  mucous  membrane  almost  instantly  assumes  a  deep  flesh  color, 
and  presently  a  dark,  blackish  spot  is  seen  streaked  with  blood. 
The  following  day  the  tonsil  is  covered  with  a  whitish -yellow 
eschar. 

"  The  inconsiderable  amount  of  suffering  produced  by  this  applica- 
tion is  noticeable.  Children  hardly  pay  any  attention  to  the  pain, 
or  make  light  of  it.  At  the  longest,  the  discomfort  lasts  only  about 
two  or  three  minutes.  Subsequent  applications  are  accompanied 
with  less,  if  any  pain  at  all. 

"  The  operation  is  again  to  be  repeated  in  two  or  three  days.  The 
number  of  applications  will  depend  upon  the  nature  of  the  case. 

"Our  author  reports  one  hundred  and  twenty-three  cases  treated 
in  this  manner:  the  minimum  numljcr  of  applications  of  the  paste, 
in  any  case,  was  six;  the  maximum,  fourteen." — Modern  Therapeu- 
tics. 

The  good  results  obtained  from  the  use  of  this  paste  are  not 
exaggerated  by  Dr.  Ruppaner.  Still,  the  experience  of  the  author 
makes  him  unwilling  to  agree  that  such  mode  of  cure  should  be 
found  to  dispense  entirely  with  the  use  of  the  knife.  Excision  of  the 
tonsils  is  an  operation  of  almost  instantaneous  performance,  and  the 
results  may  be  said  to  be  always  compieie.  The  practitioner  who  is 
inexperienced  in  the  use  of  the  knife  may,  however,  place  full  con- 
fidence in  the  use  of  the  London  paste. 

Dr.  Rumbold,  of  St.  Louis,  Missouri  {Medical  Archives),  claims 
to  have  treated  successfully  a  number  of  cases  of  enlarged  tonsils 
by  injecting  the  glands,  by  means  of  a  hypodermic  syringe,  with  a 
solution  of  iodine  (B. — lodinii,  gr.  ij;  potassii  iodidi,  9ij ;  aquae,  ^j). 
Generally  a  slight  inflammation  followed  the  injection,  but  it  soon 
subsided.  From  twelve  to  seventeen  injections — ordinarily  two  a 
week — were  sufficient  to  reduce  the  gland  to  its  normal  condition. 
The  advantage  claimed  for  this  mode  of  treatment  was  its  saving 
the  substance  and  function  of  the  gland. 

Amputation  of  the  enlarged  tonsil  is  to  be  effected  either  with 
the  bistoury  or  the  tonsillotome,  the  latter  instrument  being  that 
which  most  recommends  itself.  Fik-.  221  exhibits  such  an  instrument. 


THE    TONSIL   GLANDS. 


523 


Fig.  221. 


The  principle  of  the  tonsillotome  is  that  of  the  guillotine.  Of  these 
instruments  there  are  a  variety,  a  single  mode  of  operation  being 
common,  however,  to  all  of  them.  The  con- 
struction embraces,  first,  a  fenestra,  to  encir- 
cle the  gland  ;  second,  a  slide-pin,  to  catch 
and  hold  the  organ ;  and  third,  a  triangular 
blade,  for  the  excision.  Of  these  instruments, 
some  cut  by  having  the  knife  drawn  forward. 
This  is  the  manner  of  that  known  as  the 
Fahnestock  blade.  Others,  as  the  Physick,  have 
the  motion  forward.  An  improvement  lately 
made  on  the  Physick  instrument,  by  Mr. 
Kolbe,  consists  in  an  addition  of  automatic 
fingers  and  ringed  lever-handles.  To  use  this 
instrument  it  is  only  necessary  to  carry  the 
fenestra  over  the  gland,  when,  by  the  simple 
closure  of  the  handles,  the  fingers  grasp  and 
pull  the  gland  under  the  blade,  which,  in  a 
synchronous  movement,  cuts  jt  off. 

To  apply  the  tonsillotome  to  the  gland  of 
the  right  side,  the  surgeon  finds  his  greatest 
convenience  in  leaning  over  the  thrown-back 
head  of  the  patient.  In  using  it  for  the  left 
side,  there  is  no  better  manner  than  to  rest  in 
front  of  the  patient  upon  the  right  knee,  thus 
placing  the  fenestra  with  facility,  and,  if  the 
Kolbe  instrument  is  used,  holding  it,  while  the 

handles  are  manipulated  by  an  assistant.  In  using  any  of  the  slide- 
pin  instruments,  both  pin  and  blade  are  best  worked  by  the  assistant, 
the  surgeon  fixing  and  retaining  the  fenestra  exactly  where  it  is 
desired  that  the  section  shall  be  made. 

In  using  the  ordinary  tonsillotome,  occasion  is  not  unfrequently 
found  for  the  employment  of  means  which  shall  allow  of  the  gland 
being  enveloped  in  the  fenestra.  When  such  diflBculty  is  met,  it 
complicates  the  operation  to  some  extent,  yet  is  easily  to  be  over- 
come through  the  use  of  a  vulsellum,  the  gland  by  this  means  being 
caught  and  dragged  within  the  ring. 

The  use  of  the  bistoury  as  a  means  for  the  amputation  of  a  tonsil 
gland  is  only  to  be  indorsed  when  in  most  experienced  and  skillful 
hands ;  results  of  the  gravest  nature  might  very  readily  arise 
through  some  unexpected  and  unanticipated  movement  on  the  part 


Tonsillotome — Physick. 


524  ORAL  DISEASES  AND   SDRGERY. 

of  the  patient, — a  risk  entirely  avoided  in  the  use  of  the  first  instru- 
ment. 

In  operations  upon  young  children  with  the  tonsillotome,  it  will 
be  found  best  to  employ  ether,  as  otherwise  the  restlessness  may 
interfere  with  the  proper  introduction  of  the  instrument.  After  the 
excision  of  one  tonsil  the  child  should  have  its  head  immediately 
thrown  forward,  that  the  blood  may  not  pass  into  the  throat.  As 
soon  as  hemorrhage  has  stopped,  the  ether  may  be  readministered, 
and  the  section  repeated  upon  the  opposite  side. 

Questions,  however,  will  arise  as  to  the  advisability  of  the  double 
operation  at  the  same  sitting, — questions  of  shock,  of  hemorrhage, 
of  inflammatory  sequelae,  of  idiosyncrasy.  The  experience  of  the 
author  favors  most  decidedly  two  operations,  the  first  to  be  in  every 
respect  recovered  from  before  the  second  is  attempted^ — not,  how- 
ever, that  it  is  meant  to  imply  that  such  care  and  caution  are  always 
necessary,  or  that  indeed  the  single  operation  is  his  own  constant 
practice:  it  is  suggested  as  that  attended  with  least  risk. 

Many  surgeons,  immediately  after  this  operation,  and  in  many 
instances  before  it,  administer,  in  anticipation  of  inflammatory 
trouble,  a  full  dose  of  sulphate  of  magnesia.  It  is  also  thought 
well  by  many  to  protect  the  incised  parts  against  the  irritating 
influence  of  atmospheric  changes  by  a  confinement  of  several  days 
in  an  even  temperature.  It  may  be  accepted,  however,  that,  if  the 
weather  be  moderately  mild,  it  will  be  found  sufficient  to  keep 
the  parts  lubricated  by  a  coating  of  gum  acacia,  secured  by  simply 
holding  the  pearls  in  the  mouth  until  they  dissolve. 

Hemorrhage,  of  any  marked  character,  after  the  operation,  is  not 
common  ;  instances  occur,  however,  where  the  tonsillar  artery  must 
be  compressed,  twisted,  or  tied ;  but,  as  a  rule,  there  is  no  trouble 
from  this  source  which  a  simple  gargle  of  alum-water  will  not  be 
quite  sufficient  to  overcome. 

Of  other  surgical  conditions  associated  with  the  amygdalae,  ulcera- 
tion is,  without  doubt,  the  most  common.  Of  the  non-specific 
ulcers,  all  will  be  recognized  to  have  the  expression  as  described 
under  the  head  of  "  the  Aphihae"  (which  see).  Specific  ulcers  are  of 
two  kinds,  the  venereal  and  the  cancerous.  A  diagnosis  of  the  former 
is  readily  to  be  made  from  the  expressions  found  associated  in  other 
parts  of  the  mouth.*     The  cancerous  ulcer,  being  of  the  epithelial 


*  "The  syphiliticaffectionsof  the  tonsils  arcdifficulttodiagnose, since  even 
in  relative  good  health  considerable  swelling,  Assuring,  partial  loss,  excoria- 


THE    TONSIL    GLANDS.  525 

Tariety,  is  to  be  recognized  in  the  papilliform  character  of  the  gran- 
ulation, with  which  its  surface  is  always  found  studded.  The 
treatment  of  the  first  is  to  be  that  directed  to  the  cure  of  the  in- 
fluencing disease.  (See  Ulcers.)  That  of  the  second  may  only  be 
founded  on  the  most  careful  weighing  of  the  circumstances  of  each 
case.  Should  such  disease  be  recognized  in  its  true  character,  when 
very  circumscribed  and  non-infiltrated,  it  is  justifiable  to  extirpate 
the  gland.  If  not  appreciated  until  the  neighboring  mucous  mem- 
brane manifests  its  sympathy,  an  operation  would  be  worse  than 
useless.  It  has  happened  to  the  author  to  be  consulted  in  several 
cases  of  epithelioma  of  the  tonsil  glands,  but  he  has  never  seen  one 
which  warranted  operation. 

Constitutional  cancer,  as  a  primary  exhibition,  is  described  as 
being  seen  in  this  gland.  The  author  has  never  met  with  it  except 
by  implication. 

Complete  extirpation  of  the  gland,  when  indicated  for  a  cancerous 
manifestation,  would  be  best  practiced  by  external  incision.  An 
operation  so  performed  is  recorded  by  Dr.  Cheever,  of  Boston.  In 
this  case  two  incisions  were  made  :  one  commencing  within  the  angle 
of  the  jaw,  and  directed  downward  on  a  line  parallel  with  the  sterno- 
cleido-mastoideus ;  the  second  forward,  along  the  base  of  the  jaw. 
The  dissection  in  this  case  revealed,  first,  an  enlarged  lymphatic 
gland,  which  was  removed;  second,  the  digastric,  stylo-hyoid  and 
siylo-glossus  muscles,  these  being  cut  and  pushed  aside ;  and  third,  the 
superior  pharyngeal  constrictor,  the  fibres  of  which  were  disparted, 
thus  allowing  the  finger  to  reach  and  retract  the  gland.  Twelve 
ligatures  controlled  the  hemorrhage  of  the  operation,  and  the  patient 

tions,  follicular  abscesses,  and  cicatrices  may  frequently  affect  these  organs 
and  yet  remain  unnoticed.  The  crypts  of  the  tonsils  sometimes  form  exten- 
sive fistulous  passages,  thus  constituting  a  persistent  cause  of  altered  secretion 
and  of  increased  sensibility.  If  the  hypertrophied  tonsils  are  not  removed, 
the  surgeon  should  at  least  slit  up  these  fistulous  canals  or  cauterize  them  to 
a  sutfieient  depth.  Of  the  ordinarj'  caustics,  Prof.  Sigmund  prefers  to  nitrate 
of  silver  or  bichloride  of  mercury  the  Vienna  paste,  immediately  after  the 
application  of  which  the  cauterized  spot  is  to  be  washed  with  vinegar  and 
water.  Concentrated  tincture  of  iodine  may  also  be  applied  to  ulcers  with 
good  results.  Tannin  is  applied  principally  as  a  wash  after  the  use  of  caus- 
tics, or  as  a  retaining  agent  after  brushing  over  the  parts  with  tincture  of 
iodine.  All  these  applications,  however,  may  be  spared  if  the  surgeon  at 
once  removes  the  hypertrophied  tonsils,  the  most  certain  means  of  alle- 
viating and  cutting  short  the  course  of  syphilis  in  these  organs." — SclunidVs 
Jahrbucher. 


526  ORAL  DISEASES  AND   SURGEBY. 

is  reported  as  having  completely  recovered  in  a  month.  Extirpation 
of  the  gland  from  within  tlie  mouth  has  been  successfully  accom- 
plished both  by  European  and  American  surgeons.  In  a  gland  well 
solidified  by  the  scirrhous  expression,  and  possessed  of  a  well-defined 
base,  a  catgut  or  wire  ecraseur  is  to  be  used  with  great  satisfaction. 

Cystic  Disease. — The  formation  of  a  cyst  or  cysts  within  the 
gland  is  of  rare  occurrence.  In  his  own  immediate  practice,  the 
author  has  as  yet  never  seen  a  case.  Virchow,  in  his  volume  on 
Tumors,  mentions  them,  however,  as  being  of  not  infrequent  oc- 
currence. The  signification  of  such  a  cyst  would  most  likely  be 
found  in  occlusion  of  an  orifice  of  outlet,  while  the  treatment  de- 
manded would  be  of  such  simple  nature  as  applies  to  abscess  or 
ranuia.  Should  a  cyst  prove  of  malignant  character,  little  harm 
would  result  from  mistaking  it  for  and  treating  it  as^otie  of  simple 
form.  The  diagnosis  of  a  cystic  tonsil  would  necessarily  result  on 
touching  such  a  cyst. 

Abscess. — Abscess  of  strumous  signification  is  frequently  to  be 
met  with  in  these  glands.  These  abscesses  belong  truly  to  the 
cold  or  chronic  variety,  being  oftentimes  two  or  three  months  in 
maturing,  seldom  attended  with  pain,  and  imparting  to  the  over- 
lying structure  a  dull  white  appearance,  very  characteristic.  Such 
abscesses  are  to  be  treated  from  the  constitutional  as  well  as  from 
a  local  standpoint.  As  a  gargle,  to  be  used  several  times  a  day, 
no  medicament  seems  to  equal  the  compound  tincture  of  capsicum, 
3'j  to  ov^i'j  of  water  being  employed.  Internally,  cod-liver  oil, 
combined  with  a  chalybeate,  will  be  found  of  the  greatest  service, 
and  may  be  prescribed  with  great  freedom. 

Occasions  will  be  found  to  present,  where,  in  acute  tonsillar  dis- 
ease, the  surgeon,  called  in  an  emergency,  is  compelled  quickly  to 
decide  on  means  which  involve  life  or  death.  For  such  emergencies 
a  judicious  practitioner  fully  prepares  himself. 

When  convinced  that  a  patient  may  not  otherwise  be  relieved,  and 
suffocation  is  imminent,  the  surgeon  may,  without  hesitation,  thrust 
,  a  bistoury  or  scalpel  directly  through  the  crico-thyroid  membrane. 
This  operation,  if  no  middle  thyroid  artery  run  over  the  membrane, 
is  one  of  most  simple  character  ;  and  if  the  parts  be  then  separated, 
and  kept  so,  either  by  the  introduction  of  a  tube,  or  by  hooks  of  wire, 
which  may  pass  around  the  neck,  the  patient  will  experience  the 
greatest  relief.     When  the  artery  crosses  the  membrane,  and  has 


THE   TONSIL   GLANDS. 


527 


thus  been  cut,  the  blood  is  to  be  prevented  from  entering  the  lungs 
by  leaning  the  person  forward,  the  face  downward;   the  vessel  is 

Tig.  222. — View  of  the  Air-Tubes. 


A.  Larynx,  trachea,  and  bronchial  tubes,  viewed  in  front.  1,  hyoid  bone ;  2,  tliyro-hyoid 
membrane;  3,  tliyroid  cartilage;  4,  crico-thyroid  membrane;  5,  cricoid  cartilage;  6, 
trachea;  7,  8,  two  cartilaginous  rings;  9,  membrane  which  separates  them ;  10,  right 
bronchus  and  its  divisions;  11,  left  bronchus. 

B.  Larynx,  trachea,  and  commencement  of  bronchial  tubes,  viewed  from  behind.  1, 
upper  opening  of  larynx  ;  2, 3,  lateral  grooves  of  larynx ;  4,  fibrous  membrane  of  trachea, 
interspersed  with  small  glands,  beneath  which  are  seen  5,  muscular  fibres;  beneath  this 
last  are  6,  7,  small  fibrous  bands;  8,  mucous  membrane  seen  between  them. 

then  to  be  secured  in  the  most  convenient  manner,  with  ligature,  if 
possible. 

Tracheotomy,  an  operation  sometimes  in  such  connection  found 
compulsory,  while  seemingly  complex,  is  yet  not  difficult  of  accom- 
plishment: at  least  the  author  has  found  himself  able  to  perform  it 
upon  the  living  subject  without  assistance.  Having  the  patient 
upon  his  back,  with  the  neck  extended,  an  incision  is  to  be  made 
directly  in  the  middle  line  of  the  neck:  this  incision,  under  the  cir- 


528  ORAL  DISEASES  AND   SURGERY. 

cumstances  we  are  considering,  may  be  quite  short,  and  is  to  be 
commenced  immediately  below  the  cricoid  cartilage.  Dividing  skin, 
superficial  fascia,  and  the  delicate  layer  of  the  deep  fascia,  we  come 
upon  the  muscles  running  from  the  sternum  to  the  os  hyoides  and 
thyroid  cartilage.  Seeking  the  interspace  separating  these  muscles, 
they  are  thrust  to  either  side, — which  is  easily  done  by  using  the 
handle  of  the  knife.  The  thyroid  plexus  of  veins  is  now  brought 
into  view,  and  is  to  be  carried  aside  or  ligated,  as  seems  most  con- 
venient :  these  manipulations  bring  into  view  the  trachea  with  its 
rings.  Take  now  the  tenaculum,  and,  steadying  the  tube  by  pulling 
it  upward,  incise  one,  two,  or  three  rings. 

The  operation  thus  accomplished,  keep  the  incision  open  by  the 
use  of  the  wire,  or,  if  preferred,  introduce  the  canula  and  maintain  it 
in  place  by  the  strap,  as  seen  in  Sul^fig.  6,  Plate  VII. 

In  performing  the  operation,  it  is  also  necessary  to  bear  in  mind 
that  occasionally  the  inferior  thyroid  artery  is  found  lying  upon  the 
trachea,  directly  in  its  middle  line.  When  this  vessel  is  seen,  it 
becomes  necessary  to  throw  a  ligature  around  it.  Observations  in 
the  dissecting-room  would  lead  to  the  inference  of  the  presence  of 
the  artery  in  this  position  in  about  one  out  of  six  cases. 

OEdema  of  the  glottis,  a  condition  sometimes  associated  with 
acute  tonsillitis,  is  a  very  dangerous  complication,  being  found 
generally  in  the  weak  and  anaemic.  This  complication,  when  really 
threatening,  may  be  aborted  by  blistering  the  neck  with  cantharidal 
collodion,  and  afterward  keeping  up  the  watery  discharge  by  paint- 
ing the  parts  with  glycerine.  If,  however,  sucli  a  treatment  is  not 
quickly  responded  to,  the  surgeon  finds  himself  compelled  to  scarify 
the  parts.  Subtig.  8  represents  this  swollen  condition  of  the  glottis. 
To  scarify  these  parts,  seat  the  patient  upon  a  chair,  and,  throwing 
the  head  well  back,  introduce  the  finger  until  it  shall  touch  the 
epiglottis ;  pressing  now  this  organ  toward  the  base  of  the  tongue 
so  that  the  finger  shall  be  back  of  it,  carry  a  curved  and  wrapped 
bistoury  along  the  finger  until  it  shall  reach  the  swelling;  cuts  are 
now  to  be  made  from  below  forward.  If  the  epiglottis  is  the  part 
afi'ected  (and  this  is  most  commonh^  the  case),  the  operation  is  ren- 
dered much  easier;  steadying  the  organ  with  the  finger,  the  part  is 
to  be  incised  as  in  the  first  instance.  Subfig.  7  represents  oedema 
of  the  epiglottis. 

Amputation  of  the  Uvula. — Conditions  requiring  amputation  of 


THE    TONSIL    GLANDS.  529 

the  uvula  are,  relaxations  of  th'e  mucous  membrane  refusing  to 
respond  to  medication ;  cedema,  when  extent  of  enlargement  en- 
dangers life;  hypertrophy  interfering  with  function. 

The  first  and  second  of  these  conditions  require  alone  excision  of 
the  tip  of  the  organ.  In  the  first  is  demanded  the  removal  of  that 
superabundance  of  the  membrane  so  plainly  to  be  seen,  falling  life- 
lessly as  it  does  upon  the  dorsum  of  the  tongue,  and  being  frequently 
provocative  of  an  irritation  which,  without  the  relief  of  operation, 
endangers  the  lungs  of  the  patient.  In  the  second  condition  all  that 
is  required  is  the  snipping  of  the  slightest  portion,  a  puncture  being- 
sufficient  to  drain  away  the  serum  occupying  the  cellular  tissue  Ijing 
between  and  associating  the  muscular  and  mucous  structures. 

In  the  third  of  the  conditions,  a  diversity  in  practice  exists.  The 
weight  of  experience  seems  to  favor  complete  amputation  of  the 
organ,  the  objection  to  partial  amputation  being  the  certainty  of 
regrowth. 

As  one  of  the  offices  of  the  uvula  is,  however,  to  convey  the 
mucus  and  saliva  about  the  base  of  the  tongue  and  epiglottis,  acting 
thus  as  an  agent  of  lubrication  to  these  parts,  it  is  objected  that  the 
removal  of  the  organ  results  in  a  dryness  of  these  parts  more 
irritating  than  the  offense  removed.  In  hypertrophy  of  the  organ, 
the  objection,  it  will  be  seen,  holds  good  only  as  absolute  necessity 
for  such  means  of  cure  might  be  in  doubt.* 

*  As  an  argument  against  the  too  free  amputation  of  the  uvula,  the  following 
views  on  the  "  Uses  of  the  Uvula,"  by  Sir  Duncan  Gibbs,  are  to  be  con- 
sidered : 

"  Anatomists  describe  the  action  of  the  uvula  muscle  as  an  elevator  which 
shortens  the  uvula.  It  is,  however,  a  sentinel  to  the  fauces,  especially  in  the 
act  of  deglutition ;  for  when  any  substance  conies  into  contact  with  it,  it 
excites  the  action  of  all  the  neighboring  muscles  until  it  is  got  rid  of.  It 
possesses  a  function  of  not  less  importance,  in  holding  the  soft  palate  tense 
and  firm  in  the  median  line  against  the  wall  of  the  pharynx  during  the  act 
of  deglutition  itself,  and  thus  prevents  the  passage  upward  of  fluid  or  solid 
substances  behind  the  nose.  This  was  supported  by  experiments  upon  a  per- 
son who  had  lost  the  bones  of  the  nose,  permitting  of  a  view  of  the  action  of 
the  soft  palate  from  its  nasal  aspect  during  deglutition,  with  or  without  food. 
Under  either  circumstance,  a  double  arch  was  seen,  in  the  form  of  two 
convex  swellings  held  in  a  state  of  firm  tension  by  the  action  of  the  uvula 
passing  down  the  centre  of  the  soft  palate,  with  its  end  resting  flat  against  the 
wall  of  the  pharynx.  The  tension  ceased  the  moment  that  the  constrictors 
of  the  pharynx  had  fully  exerted  their  influence  over  the  substance  swallowed. 
While  the  uvula  has  its  special  uses  in  the  act  of  deglutition,  it  exerts  a  not 
less  decisive  influence  upon  the  voice  when  uttered  in  very  loud  tone,  or  in 

34 


530  ORAL  DISEASES  AND   SURGERY. 

Laxity  of  the  soft  palate  itself  is  not  to  be  allowed  to  deceive 
as  to  the  condition  of  the  uvula ;  persons  of  weakly  constitutions 
being  very  subject  to  such  relaxations,  the  uvula,  while  of  normal 
length,  dragging  upon  the  underlying  parts.  Here  no  operation  is 
required,  but  rather  that  regard  and  attention  to  the  restoration  of 
the  lost  tonicity  which  is  the  indication  in  all  such  cases. 
.  Amputation  of  the  uvula  is  an  operation  of  most  simple  character. 
Standing  behind  or  in  front  of  the  patient,  as  may  be  preferred,  the 
tongue  is  depressed  with  the  handle  of  a  spoon  or  other  convenient 
means,  when  the  tip  of  the  organ,  being  seized  with  a  pair  of  forceps, 
and  dragged  forward  and  thus  steadied,  is  cut  off  at  the  place  of 
election. 

Fio.  223.— Uvula  Scissors. 


Another  manner  of  amputation  is  found  in  the  use  of  the  uvula 
scissors  (Fig.  223).  This,  as  is  seen  by  the  diagram,  consists  of  blades 
attached  to  long,  delicate  handles,  having  associated  and  working 
with  the  blades  an  arrangement  by  which  as  the  part  is  cut  off  it 
is  caught,  and  thus  prevented  from  falling  into  the  glottis.  These 
scissors  do  away  with  the  necessity  for  the  use  of  the  forceps. 

Hemorrhage  from  amputation  of  the  uvula  will  seldom  be  found 
to  require  attention.  The  author  has  operated  a  great  number  of 
times,  and  never,  except  in  one  instance,  met  with  bleeding  to  an 
extent  requiring  attention  ;  in  this  one  case  it  yielded  to  a  gargle  of 
alum-water  used  once.  A  feeling  of  rawness  associated  with  the 
excision,  and  which  is  the  principal  associated  complaint,  will  be 
found  corrected  through  the  use  of  crystals  of  gum  arable  held  in 
the  mouth,  or,  if  preferred,  jujube  paste  may  be  used, — solid  food 
being  excluded  from  the  diet  for  a  short  time. 

singing  the  higher  registers,  in  both  sexes ;  then  its  character  as  a  levator  or 
shortener  is  exerted.  If  this  power  is  impaired  by  removing  the  muscular 
(not  the  membranous)  end,  then  the  singing  powers  are  damaged.  Speech 
is  modulated  by  the  soft  palate  and  uvula,  and  the  motor  power  of  the  latter 
is  unquestionably  exerted  in  pronouncing  the  letters  K,  Q,  and  X,  with  their 
associations,  more  especially  the  gutturals  of  the  various  languages." 


f 


Fio  1 


ri;ilr   VII 


f IP   2 


Yii  ?, 


T" 


PLATE     VII. 

A    VIEW    OF    THE    OPERATIONS   PERFORMED    ON    THE    TRACHEA. 

Fir,.  I. — A  front  view  of  the  Surgical  Anatomy  of  the  Trachea.  1.  Oshyoides. 
2.  Thyroid  cartilage.  3.  Thyro-hyoid  muscles.  4.  Crico-thyroid 
muscles.  5.  Thyroid  gland  and  veins  in  front  of  crico-thyroid 
ligament.  6.  Rings  of  the  trachea.  7.  Common  carotid  artery. 
8.  Superior  thyroid  arteries.  9.  Inferior  thyroid  artery.  10. 
Carotid  artery,  as  divided.  11.  Outline  of  the  top  of  the  chest. 
12.  Innominata  artery.  13.  Inferior  thyroid  vein.  14.  Trans- 
verse vein. — After  Bernard  and  Huette. 

Fig.  2. — Relative  position  of  the  Larynx,  Trachea,  and  Blood-vessels.  1. 
Os  hyoides.  2.  Thyro-hyoid  ligament.  3.  Thyroid  cartilages. 
4.  Crico-thyroid  ligament.  5.  Cricoid  cartilage.  6.  Trachea.  7. 
Internal  jugular  vein.  8.  Transverse  vein.  9.  End  of  inferior 
thyroid  vein.     10.  Veins. — After  Bernard  and  Huette. 

Fig.  3. — Relative  positions  of  the  great  vessels  concerned  in  operations  near 
the  top  of  the  sternum.  1,  1.  Internal  jugular  vein.  2,  2.  Sub- 
clavian veins.  3.  Subclavian  artery.  4.  Transverse  vein.  5.  In- 
ferior thyroid  vein,  6.  External  jugular  vein.  7.  Arch  of  the 
aorta.     8,  8.  Primitive  carotids. — After  Bernard  and  Huette. 

Fig.  4. — A  view  of  the  operation  of  Tracheotomy,  as  performed  by  Mr.  Lis- 
ton.  1.  The  tenaculum  inserted  into  the  trachea.  2.  Position  of 
the  bistoury  in  incising  the  rings.  3.  Line  and  termination  of  the 
external  incision. — After  Liston. 

Fig.  5. — Extraction  of  a  foreign  body  by  Tracheotomy,  the  head  being  thrown 
back  and  lowered,  so  as  to  facilitate  the  gravitation  of  the  object, 
1,  1.  Blunt  hooks  holding  open  the  wound.  2.  Hand  of  the  sur- 
geon in  the  act  of  extracting  the  foreign  body,  by  drawing  it 
upward  from  the  bronchia. — After  Bourgery  and  Jacob. 

Fig.  6. — A  front  view  of  the  position  and  mode  of  retaining  a  canula  in  the 
Trachea,  as  usually  practiced.  1.  The  incision.  2,  2.  A  tape 
attached  to  the  wings  of  the  canula  and  passing  around  the 
neck. — After  Bernard  and  Huette. 

Fig.  7. — The  appearance  of  the  parts  concerned  in  (Edema  of  the  Glottis,  1. 
The  epiglottis  cartilage,  much  swollen  by  serous  infiltration  of  its 
submucous  cellular  tissue. — After  Guerdon  Buck,  Jr. 

Fig.  8. — The  operation  of  scarifying  the  Glottis  for  the  relief  of  ffidema.  1. 
The  forefinger  in  its  position  as  a  director.  2.  The  knife  in  the 
act  of  scarifying  the  part. — After  Gurdon  Buck,  Jr. 

(531) 


CHAPTER   XX  Y  I. 


THE   GUMS   AND   THEIR   DISEASES. 


The  gums  are  simply  an  amount  of  fibro-cartilaginous  tissue  (the 
fibrous  element  greatly  predominating)  placed  as  protecting  cushions 
about  the  alveolar  processes.  The  neck  of  each  tooth  is  closely 
enveloped  by  the  dental  pits  of  this  cushion  ;  the  raucous  mem- 
brane, which  covers  the  common  surface,  being  reflected  around  the 
pits,  and  rendered  continuous  with  the  periosteum  of  the  alveoli. 

The  gums,  in  a  healthy  state,  are  rather  remarkable  for  their  in- 
sensibility, bearing,  Avith  very  little  or  no  response,  the  pressure 
and  irritation  to  which,  in  the  process  of  mastication,  they  are  so 
continuously  subjected.  The  mucous  membrane,  of  which  this 
tissue  is  largely  made  up,  is  very  heavy  and  thick  as  compared 
with  its  continuity  in  other  parts  of  the  alimentary  canal,  and  is 
underlaid  by  a  network  of  vessels,  which  leads  it  to  be  esteemed  of 
considerable  vascularity  as  reference  is  had  to  operations  involv- 
ing it. 

Inflammation  is  the  disease  of  the  gums  ;  but  such  perverted  vas- 
cular action,  here,  as  everywhere  else,  has  quite  a  variety  of  signifi- 
cations.    These  significations  are — 

1.  Accumulations  of  tartar. 

2.  Periodontitis. 

3.  The  mercurial  impression. 

4.  Scurvy. 

5.  Syphilis. 

6.  Dead  or  loose  teeth. 

T.  A  crowded  dental  arch. 

8.  Use  of  improper  dentifrices  and  brushes. 

9.  Improperly  inserted  artificial  teeth. 

10.  Malignant  impressions. 

11.  Anomalous  conditions. 

A  comprehension  of  the  diseases  of  the  gums  is  found  in  the 
appreciation  of  these  various  conditions  or  influences. 
(532) 


THE   GUMS  AND    THEIR   DISEASES.  533 

1.  Accumulations  of  Tartar-. — Salivary  calculus,  a  deposit  from 
the  saliva,  combined  with  the  various  oral  detritus,  when  attached 
about  the  necks  of  the  teeth,  necessarily  becomes  a  source  of  offense, 
provoking  inflammatory  action,  the  grade  of  which  is  marked  by  the 
general  condition  of  the  individual.  The  most  common  type  of  in- 
flammation thus  induced  is  the  chronic  degenerative.  The  tartar, 
pressing  upon  the  gums  and  insinuating  itself  about  and  around  the 
necks  of  the  teeth,  soon  interferes  to  such  extent  with  the  proper 
circulation  in  the  part  as  to  yield  the  puffy,  turgid  condition  so 
familiar  in  most  of  the  cases.  The  mucous  follicles  lining  the  muco- 
dental  pits  have,  of  course,  their  secretive  ability  soon  destroyed,  and 
thus  nothing  prevents  the  insinuation  of  particles  into  these  pits, 
and  the  consequent  increase  in  the  power  of  the  offense.  This  irri- 
tation, uncombated,  gradually  progresses  until  the  teeth  become 
loosened  and  fall  out,  when,  carrying  with  them  the  tartar,  the  parts 
recover. 

All  deposits,  however,  existing  under  the  common  name  of  tartar 
or  salivary  calculus,  do  not  have- such  a  destructive  history.  Thus, 
it  is  very  common  to  observe  a  greenish  deposit,  particularly  upon 
the  teeth  of  the  robust  and  uncleanly,  which,  so  far  as  I  have  ob- 
served, seldom  results  in  any  particular  harm.  Another  kind,  the 
black,  rarely  exists  but  in  very  limited  amount,  and  as  rarely  or 
never  does  any  greater  ill  than  slightly  irritating  the  festoon  ;  its 
situation  is  most  commonly  the  lingual  face  of  the  inferior  teeth.  It 
does  happen,  however,  that  this  description  of  tartar,  or  something 
very  analogous  to  it,  is  sometimes  provoked,  as  it  were,  in  depraved 
constitutions,  to  extensive  deposit ;  it  is  a  kind  of  mixture  or  agglu- 
tination of  tartar  and  sordes.  The  gums,  from  a  constitutional  in- 
fluence very  much  depraved,  are  irritated  not  unfrequently  by  this 
jagged  deposit  into  a  state  very  little  short  of  gangrene ;  the  breath 
is  made  offensive,  and  the  oral  fluids,  by  the  admixture,  are  rendered 
entirely  unfit  to  be  received  by  the  stomach. 

Yellow  tartar,  the  deposit  of  the  bilious  and  allied  temperaments, 
is  the  kind  most  generally  met  with,  and,  as  a  rule,  is  most  destruc- 
tive to  the  integrity  of  the  teeth  and  gums.  It  is  not  at  all  uncom- 
mon to  find  this  deposit  of  such  extent  as  to  inclose  in  a  common 
mass  half  a  dozen  or  more  teeth,  while  its  power  of  insinuation  and 
destruction  is  so  great  that,  before  attention  may  have  been  directed 
to  the  process,  the  alveoli  will  be  found  destroyed  and  the  teeth 
ready  to  drop  from  the  mouth.  I  have,  in  my  own  practice,  fre- 
quently been  consulted  in  these  cases,  where  nothing  was  of  any 


534  ORAL  DISEASES  AND  SURGEBY. 

avail  but  the  removal  of  the  implicated  teeth.  This  description  of 
calculus  is  evidently  a  direct  deposit  from  the  saliva,  its  situation 
corresponding  with  the  location  of  the  salivary  orifices.  I  think  it 
will  be  found  always  associated  with  a  sluggish  condition  of  the 
secretive  action  of  the  glands,  as  I  am  sure  its  most  reliable  prophy- 
laxis is  found  in  their  stimulation.  This  tartar  has  a  rough,  dry 
surface,  and  is  generally  most  easy  of  removal,  flaking  away  in 
masses  at  the  slightest  touch  of  the  instrument.  The  effect  of  its 
presence  upon  the  gum  is  to  force  it  away  from  the  teeth,  or  rather, 
it  might  be  more  correct  to  say,  to  lift  the  teeth  from  the  gums  and 
their  alveoli,  destroying  entirely  any  relation  of  attachment  between 
the  parts.  The  gums  themselves,  under  its  irritating  influence,  be- 
come pufiFy  and  soft,  and  occasionally  so  tender  as  to  render,  in  many 
cases,  unbearable  the  ordinary  pressure  exerted  in  mastication,  so 
that  the  patient  is  compelled  to  subsist  exclusively  on  soft  food,  or 
employ  other  than  the  natural  process  of  comminution,  (See  chap- 
ter on  Salivary  Calculus.) 

2.  Periodontitis. — Ulitis  from  periodontitis  is  not  at  all  difficult 
to  distinguish,  and  corresponds  in  character  with  the  primary  lesions 
in  being  acute  or  chronic.  If  a  tooth  is  acutely  inflamed  in  its  perio- 
donteum,  it  is  sore  to  the  touch,  and  elongated.  If  it  is  chronically 
inflamed,  it  is  loose  or  discolored.  Inflammation  in  the  gum  is 
simply  an  inflammation  of  continuity.  If  the  patient  is  in  good 
health,  the  action  will  be  circumscribed  ;  if  the  reverse,  it  will  of 
course  influence.  To  treat  such  an  inflammation,  the  health  of  the 
tooth  or  teeth  is  to  be  restored.  An  inflamed  periodonteum  is  com- 
monly associated  with  a  dead  pulp ;  this  is  the  first  source  of  offense 
for  which  we  naturally  look.  If  such  a  condition  is  found,  and  no 
cavity  of  communication  exists  with  the  pulp  canal,  it  will,  in  nine 
cases  out  of  ten,  only  be  necessary  to  make  such  communication,  and 
the  trouble  quickly  enough  disappears.  Tartar  is  the  frequent  source 
of  chronic  periodontitis.  Fish-bones,  or  other  foreign  bodies,  forced 
into  the  membrane  in  mastication,  excite  inflammation. 

Acute  periodonto-ulitis  uncontrolled  ends  in  parulis,  and  from  such 
acute  termination  is  very  apt  to  pass  to  chronicity.  Chronic  ulitis 
presents  the  condition  of  continued  turgescence,  soreness,  loose  teeth, 
or  fangs ;  suppuration  frequently  occurs  at  the  seat  of  the  original 
abscess,  and  sometimes  from  the  affected  alveolar  pits.  Its  cure,  like 
that  of  the  acute  condition,  resides  in  a  treatment  directed  to  the 
teeth,     (See  Periodontitis  and  Alveolar  Abscess.) 

3,  The  Mercurial  Impression. — Mercury  first  yields   decided 


THE   GUMS  AND    THEIR   DISEASES.  535 

evidence  of  its  action  by  producing  in  the  mouth  a  metallic  taste, 
complained  of  as  coppery.  A  little  time,  and  this  taste  is  accompa- 
nied with  some  increase  in  the  quantity  of  the  saliva;  still  later  the 
festoons  of  the  gums  will  be  found  congesting,  commencing  generally 
about  the  necks  of  the  lower  central  teeth.  Succeeding  this  conges- 
tion we  have  the  dull  whiteness  indicating  the  change  in  the  epithe- 
lial tissue  (a  form  of  aphthae).  There  now  follow  the  elongation 
of  the  teeth,  increased  salivary  flow,  stiffness  of  the  gums,  enlarge- 
ment of  the  tongue,  foul  breath,  etc. 

The  effects  which  mercury  shall  produce  on  the  mouth,  or  system 
at  large,  depend  on  the  quantity  administered  and  the  susceptibility 
of  the  individual.  I  have  myself  exhibited  the  medicine  in  quantities 
of  from  fifteen  to  twenty  grains  in  the  course  of  three  days  without 
being  able  to  perceive  the  local  action  ;  while,  on  the  contrary,  I  have 
known  five  grains  so  to  swell  the  tongue  that  it  required  much  effort 
to  prevent  the  patient  being  smothered.  Children  from  five  to  ten 
years  of  age  have  seemed  to  me  markedly  susceptible.  I  removed, 
a  short  time  back,  the  whole  of  the  left  half  of  the  body  of  the  lower 
jaw,  dead  from  but  some  three  graius  of  calomel,  as  averred  by  the 
practitioner  who  administered  the  medicine.  The  patient  was  seven 
years  of  age.  Mercurial  ulitis,  when  confined  alone  to  these  parts, 
signifies  but  slight  effect  on  the  part  of  the  action  of  the  agent;  and 
the  immediate  cessation  in  its  employment  will  generally  result  in 
the  disappearance  of  these  effects.  If  this  should  not,  however,  prove 
the  case,  I  think  nothing  better  can  be  done  than  to  scarify,  and 
paint  the  gums  with  tincture  of  iodine,  graduated  to  each  particular 
case,  say,  as  a  rule,  half  and  half  of  the  officinal  tincture  and  water. 
Chlorate  of  potash  as  a  wash,  and  used  internally,  may  also  be  em- 
ployed. To  an  adult,  ten  grains  of  the  salt,  dissolved  in  a  table- 
spoonful  of  water,  may  be  given  four  or  five  times  a  day.  As  a 
local  application,  one  drachm  to  the  ounce  of  water  is  a  very  good 
strength.  The  bowels  are  to  be  kept  in  a  lax  condition  by  the  ad- 
ministration of  Seidlitz  powders  or  other  saline  cathartics.  Where 
mercurial  ulitis  passes  to  that  stage  which  results  in  the  breaking 
down  of  the  tissue  (and  this  is  sometimes  the  case  where  even 
adjacent  parts  are  not  markedly  affected),  the  treatment  required  is 
much  more  imperative,  and  pertains,  as  a  rule,  quite  as  much  to  the 
constitution  at  large  as  to  the  mouth  itself.  Locally,  the  fetor  will 
urgently  demand  attention  ;  and  one  of  the  best  means  to  correct 
this  will  be  found  in  the  use  of  a  solution  of  the  permanganate  of 
potash,  such  solution  varying  in  strength  from  two  to  ten  grains  to 


536  ORAL  DISEASES  AND  SURGERY, 

the  ounce  of  watei*.  Constitutlonall}^,  vigorous  tonic  medicaments  are 
required, — not  the  least  important  of  which  are  the  iron  and  bark 
preparations.  If  hemorrhage  intervenes,  it  may  be  necessary  to 
employ  opium  and  lead  internally;  or,  as  suggested  in  another  part 
of  this  work,  tincture  of  Erigeron  Canadense,  in  doses  of  one  or 
two  drops,  repeated  occasionally  until  such  bleeding  is  controlled. 
Locally,  cobweb  saturated  in  alum-water  may  be  used.  Laid  carefully 
upon  the  bleeding  part,  and  retained  in  position,  it  will  seldom  be 
found  to  fail.  Monsel's  solutions  should  not  be  used.  The  tendency 
in  extreme  cases  toward  sloughing  is  a  matter  constantly  to  be 
borne  in  mind.  When  the  tumefaction  is  very  great  and  indolent- 
looking,  the  parts  are  still  to  be  incised  and  the  iodine  applied ;  but 
both  remedies  are  to  be  used  with  judgment  and  caution.  I  have 
known  gums  in  the  condition  alluded  to,  and  which  might  perhaps 
have  Ijeen  recovered,  sloughed  in  mass  by  applications  of  strong 
tincture  of  iodine.  Always  let  the  incisions  at  first  be  few,  and  the 
tincture  at  least  two-thirds  diluted.  The  dilute  aromatic  sulphuric 
acid  is  also  a  happy  local  remedy  in  these  conditions.  It  may  be 
mixed  with  water  until  the  acid  taste  is  comfortably  bearable, — 
about  5j  to  ovi'j  of  water.  A  combination  for  local  use,  which  I 
also  occasionally  employ  with  much  benefit,  is  composed  as  follows  : 

R. — Potassa3  chloratis,  sss; 
Sodae  biboratis, 
Ahiminis  pulveris,  aa.  511 ; 
Potassse  permanganatis,  gr.  xxv  ; 
Aquse  Colonias,  3j ; 
Tincturaj  cTnchonte,  5ij ; 
Tincturae  myrrhse,  3J ; 
Tincturoe  capsici,  5.) ; 
Tincture  kramerife,  %'] ; 
Aqute,  3viij.     M. 

If,  in  defiance  of  all  that  is  done,  the  parts  should  slough,  one  of 
three  things  occurs :  the  disease  will  seem  to  have  exhausted  itself, 
and  the  parts,  after  a  little  rest,  give  evidence  of  recovery;  or  the 
bone  follows  the  ulcerative  action,  and  sloughs  likewise ;  or  the 
patient  dies  from  irritation  and  exhaustion.  (For  treatment  of  Caries 
and  Necrosis,  see  other  pages.) 

4.  Scurvy. — Scurvy  proper,  such  as  decimated  the  legions  of 
Louis  the  Ninth,  and   in  even  later  da3's  was  so  frequently  the 


I 


THE   GUMS  AND    THEIR   DISEASES.  537 

scourge  of  protracted  sea-voyages,  is  a  condition  which  modern 
science  and  judgment  have  so  combated  that  it  may  be  trusted  that 
few  of  us  will  ever  have  occasion  to  meet  with  or  ti"eat  it.  Modified 
forms  of  the  disease  are  still,  however,  prevalent  enough,  and  exist, 
with  great  variety  of  features,  from  simple  indolent  ulitis  to  general 
purpura. 

PufBness  of  the  gums,  scorbutic  in  nature,  is  fairly  judged,  I  think, 
from  its  dull,  purple  aspect,  independent  of  its  varying  constitutional 
conditions.  This  venous  congestion  compares  pathologically  with  the 
effusions  of  purpura  proper.  It  would  not,  however,  be  at  all  truth- 
ful, or  in  accordance  with  the  facts,  to  describe  any  particular  train 
of  constitutional  conditions  as  constantly  associated  with  the  scor- 
butic sore  mouth,  as  met  with  in  ordinary  practice,  and  for  the  reason 
that  nothing  else  of  the  disease  may  appear  but  the  local  manifesta- 
tion. That  it  is  a  constitutional  affection,  and  not  a  local  disease, 
is  proven  by  the  fact  of  absence  of  any  source  of  local  irritation, 
and  by  the  further  fact  of  its  constant  presence  in  the  mouth,  let 
the  disease  possess  whatever  other  uianifestations  it  may. 

Dr.  Foltz,  U.S.N.,  in  a  report  made  by  him  on  the  scurvy  which 
appeared  in  the  blockading  fleet  of  the  Gulf  of  Mexico,  states  that 
"  lassitude  and  indisposition  to  muscular  energy,  noted  so  frequently 
by  authors  as  prodroma,  were  not  among  the  symptoms  which 
ushered  in  the  disease,  and  that  there  was  great  activity,  and  not 
unfrequently  cheerfulness,  good  appetite,  and  sound  sleep  at  night, 
after  the  teeth  were  loosened,  the  gums  ulcerated,  the  limbs  oede- 
matous  and  discolored ;  and  when  at  last  the  patient  gave  way,  it 
was  not  an  indisposition  to  corporal  exertion,  but  an  actual  dis- 
ability." 

Authors,  however  they  may  disagree  in  their  descriptions  of 
such  various  cases  as  have  come  under  their  observation,  are  all 
agreed  that  scurvy  results  from  the  absence  of  fresh  fruits  and  vege- 
tables, or  their  juices,  necessary  to  furnish  some  principle  required 
in  the  blood,  and  which  is  not,  in  such  absence,  otherwise  obtained. 
In  the  treatise  published  by  Dr.  Hamilton  on  Military  Surgery,  the 
author  says,  "In  regard  to  the  pathology  of  scurvy,  the  belief  pre- 
vails that  it  is  due  essentially  to  the  absence  of  certain  staminal 
principles  from  the  blood,  and  especially  potash.  It  appears  to  be 
a  pretty  well  ascertained  fact  that  all,  or  nearly  all,  of  those  reme- 
dies which  have  been  employed  successfully  in  the  prevention  or 
cure  of  scurvy,  contain  potash.  Potatoes,  cabbage,  celery,  lettuce, 
lime-,  lemon-,  and  orange-juice,  contain  it  in  large  quantity,  unless 


538  ORAL  DISEASES  AND  SURGERY. 

their  salts  have  been  expressed  by  the  application  of  heat,  as  in 
boiling,  or  other  modes  of  cooking.  Lime-,  lemon-,  and  orange-juice 
contain  nearly  one  grain  of  potash  to  every  ounce  of  the  juice. 

"  One  ounce  of  potatoes  yields  one  grain  and  a  half,  while  one 
ounce  of  rice  yields  only  .005  of  a  grain.  The  substitution  of  rice 
in  an  English  workhouse  for  an  equal  amount  by  weight  of  potatoes 
was  followed  in  a  short  time  by  scurvy." 

In  the  ordinary  scurvy  of  the  gums,  which  every  practitioner  is 
aware  presents  itself  more  frequently  in  the  very  early  spring,  when 
the  old  vegetables  have  been  pretty  well  exhausted  and  the  fresh 
ones  have  not  begun  to  grow,  it  is  the  common  experience  to  dis- 
cover that  the  patients  have  existed  almost  exclusively  on  salt  meats  ; 
hence  it  is  much  the  most  frequently  met  with  in  the  poorer  class 
of  farm-laborers.  The  gums,  in  these  cases,  are  of  a  purple  color, 
turgid,  with  the  dental  pits  discharging  pus,  the  teeth  loosened,  the 
breath  offensive,  but  the  face  not  by  any  means  pale,  nor  the  habits 
languid :  indeed,  there  is  little  or  nothing  to  signify  that  the  local 
manifestation  is  a  systemic  offspring.  When  the  condition  is  ex- 
treme, it  is  not  uncommon  to  have  fungoid  growths  springing  from 
the  edges  and  depths  of  the  dental  pits. 

Treatment. — It  will  be  found  good  practice  to  treat  these  con- 
ditions locally,  as  directed  in  mercurial  ulitis.  Constitutionally, 
however,  different  indications  are  to  be  met ;  a  something  possessed 
by  a  vegetable  and  acid  diet  is  required  by  the  blood.  Without 
stopping  to  discuss  the  question  whether  this  may  or  may  not  be 
potash,  Ave  act  on  the  empirical  conviction,  and  at  once  direct  such 
diet.  Then  the  depressed  or  perverted  life-force  is  to  be  elevated  or 
relieved,  and  to  this  end  nothing  can  equal  the  sheet-bath,  taken 
with  water  moderately  warm  and  moderately  salt.  Saturating  the 
sheet,  it  is  quickly  thrown  around  the  body,  and  the  patient  or  an 
assistant  rubs  the  sheet  over  the  flesh  until  the  whole  person  is  in 
a  ruddy  glow.    This  is  repeated  each  morning  immediately  on  rising. 

As  medicine,  the  vegetable  acids  may  be  freely  used.  Lemonade 
is  perhaps  quite  as  good  as  anything  that  can  be  given.  A  combi- 
nation which  has  some  celebrity  is  known  as  Turner's  antidote ;  it 
consists  of  5ij  of  nitrate  of  potassa,  mixed  in  ^viij  of  acetic  acid, 
administered  in  tablespoonful  doses  three  times  a  day.  Conjoined 
with  general  medication,  attention  is  required  by  the  teeth  and  gums. 
(See  chapter  on  Salivary  Calculus.) 

5.  Syphilis. — Syphilitic  ulitis  I  judge,  from  my  own  experience 
and  observation,  to  be  an  inflammation  not  of  the  gum  tissue  proper, 


THE   GUMS  AND    THEIR   DISEASES.  539 

but  simply  of  its  mucous  envelope  ;  or,  on  the  other  hand,  it  is  an 
inflammation  commencing  in  the  periosteum,  and  secondarily  affect- 
ing the  gum  tissue.  I  do  not  think  I  have  ever  seen  a  case  of 
pure  uncomplicated  syphilitic  ulitis;  while  few  conditions  are  more 
common  than  mercurio-syphilitic  ulitis  and  osteo-ulitis  of  syphilitic 
origin.  The  appreciation  of  such  conditions  is,  of  course,  not  at 
all  difficult:  the  history  of  the  case  alone  is  sufficient  to  give  the 
diagnosis,  while  to  the  experienced  eye  a  moment's  glance  is  enough 
to  reveal  such  history.  If  the  inflammation  is  confined  to  the 
mucous  membrane,  the  full  extent  of  its  surface  will  be  more  or  less 
affected,  its  color  will  be  a  dull  red,  it  will  be  more  or  less  tender 
to  the  touch,  and  most  likely  ulcerated.  If,  on  the  contrary,  the 
bone  or  its  periosteum  is  the  primary  seat  of  trouble,  the  gum  may 
simply  be  thrown  up  by  the  effusion  beneath  it ;  or  if  it  happens  that 
the  gum  itself  has  become  inflamed,  the  action  seems  inclining  to 
localize  itself  as  much  as  possible.  This,  however,  depends  on  the 
state  of  the  parts  beneath,  and  on  the  treatment  that  is  being  pursued. 
If  the  condition  is  one  of  pure  uncomplicated  venereal  ostitis,  the 
excitement  in  the  gum  will  be  found  localized  to  the  immediately 
overlying  parts ;  but  if  there  has  been  a  mercurial  treatment,  we 
may  have  any  extent  of  complication.  The  treatment  in  these  cases 
is  to  be  founded  on  existing  conditions. 

6.  Dead  or  Loose  Teeth. — Pulpless  teeth  affect  secondarily  the 
gum  structure  through  continuity  with  the  inflamed  periodonteum. 
A  tooth  periosteally  inflamed  is  always  sore  to  the  touch,  is  more  or 
less  elongated,  and  is  discolored.  A  ulitis  connected  with  such  dis- 
eased tooth  or  teeth  is  plainly  discoverable  by  the  absence  of  other 
sources  of  irritation  ;  relief  follows,  of  course,  the  cure  of  the  primary 
lesion. 

t.  Overcrowded  Condition  of  the  Dental  Arch. — See  chapter 
on  Anomalies  of  Dentition. 

8.  Use  of  Improper  Dentifrices  and  Brushes. — Many  gums 
are  subjected  to  continuous  irritation  and  inflammation  from  the  use 
of  agents  in  the  way  of  dentifrices,  brushes,  or  other  dental  applica- 
tions, which,  either  chemically,  vitally,  or  mechanicall}",  predispose 
and  excite  to  deterioration.  Perhaps  in  the  whole  range  of  practice 
there  is,  in  no  single  instance,  less  attention  given  to  the  require- 
ments of  the  various  cases  than  is  manifested  in  the  prescribing  of 
tooth-cleansing  powders  and  washes.  Charcoal,  a  favorite  agent 
with  many,  while  excellent  in  its  place,  is  one  of  the  most  frequently 
abused  of  these  remedies.     Very  common   is  it  to  find,  after  a  few 


540  ORAL  DISEASES  AND  SURGERY. 

weeks  or  months  of  the  use  of  this  material,  the  gums  becoming 
pitted  with  black  spots  about  the  necks  of  the  teeth  and  loosening 
from  them.  This  is  a  result  of  the  insolubility  of  the  agent  in  the 
fluids  of  the  mouth  ;  gradually,  but  surely,  it  finds  its  way  into 
the  mucous  pits,  and,  not  being  either  washed  out  or  dissolved 
by  the  secretion,  it  quickly  destroys  the  integrity  of  the  relation; 
hence  follow  chronic  periodontitis  and  the  eventual  loss  of  teeth, — ■ 
the  mass  of  gum  tissue  sympathizing  during  the  whole  period, 
producing  chronic  ulitis. 

Pulverized  coral  and  pumice  are  other  agents  mechanically  de- 
structive, although  in  their  places  very  good,  and,  as  will  be  re- 
marked, recommended.  Castile  and  other  soaps,  too  freely  used, 
degenerate  by  the  action  of  their  alkalinity.  A  constant  use  of  such 
agents  is  quite  certain  to  be  attended  by  puffiness  and  chronic 
turgidity  of  the  gums,  by  degenerated  mucous  discharges,  and  by 
an  offensive  breath.  Acids,  on  the  other  hand,  employed  of  too  full 
a  strength,  inflame  and  irritate  the  gums,  and  put  the  teeth  on  edge, 
by  dissolving  more  or  less  of  their  lime  salts.  A  ulitis  from  the  irri- 
tation of  acid  agents  diS'ers,  however,  from  that  produced  by  the 
alkaline,  in  being  of  a  free,  generous,  acute,  or,  at  worst,  subacute 
nature,  easy  of  control,'  and  much  more  injurious  to  the  teeth  than 
to  the  gums  themselves.  Irritation  of  the  gums  commonly  asso- 
ciates also  with  injury  to  the  teeth. 

A  very  common  cause  of  ulitis  in  persons  with  carious  teeth 
results  from  the  too  free  use  of  creasote.  This  agent,  used  pure,  is 
a  powerful  irritant,  and  has  been  the  cause  of  some  of  the  most 
severe  acute  inflammations.  Seen  early,  the  cases  exhibit  the  direct 
effect  of  the  agent  in  the  eecharotic  result  that  has  been  produced 
on  the  mucous  membrane, — this  being  white,  pasty,  and  sloughing. 
Outside  of  the  immediate  local  use  of  oil  or  butter,  if  it  is  inferred 
that  free  creasote  remains  about  the  mouth,  such  cases  are  to  be 
treated  on  common  principles.  A  case  occurred,  a  short  time  back, 
in  my  own  practice,  where  a  girl,  with  the  intention  of  committing 
suicide,  swallowed  two  drachms  of  the  agent.  Called  immediately, 
I  used  as  an  emetic  the  first  thing  at  hand,  namely,  the  soap  on  her 
washstand,  and  followed  the  emetic  with  half  a  pound  of  common 
table-butter.  Xo  particular  bad  results  occurred:  the  patient's 
mouth,  oesophagus,  and  stomach  were  sore  for  three  days,  after 
which  she  seemed  about  as  usual.* 

*  Dr.  Theodore  Husemann  {Journal  of  Applied  Chemistry)  "  opposes  the  use 
of  fixed  oils,  glycerine,  and  similar  demulcents  in  cases  of  poisoning  by  carbolic 


THE   GUMS  AND    THEIR  DISEASES.  541 

Chloride  of  zinc,  used  in  the  mixing  of  the  so-called  bone-plugs 
now  so  freely  employed  with  the  teeth,  is  another  of  the  causes  of 
ulitis.  Its  action  may  be  of  a  twofold  character:  either  directly 
upon  the  gum  tissue,  as  by  its  careless  use  it  may  have  been  allowed 
to  come  in  contact  with  this  structure,  or  through  a  periodontitis 
excited  by  the  action  of  the  agent  on  the  dental  pulp.  From  abuse 
of  this  agent  many  cases  have  occurred  in  which  large  portions  of 
the  gums  are  destroyed  ;  and  not  unfrequently  the  action  extends 
to  the  alveolar  process,  necrosing  the  sockets  of  the  teeth. 

A  cause  of  chronic  ulitis,  which  has  been  occasionally  met  with, 
consists  in  a  wedge  of  gold  or  other  metal  forced  into  the  dental  pit 
while  in  the  act  of  filling  a  tooth  on  its  proximal  face.  A  matter 
of  this  kind  is  xevy  apt  to  be  overlooked  by  the  general  practitioner; 
hence  an  unappreciated  stubbornness  in  his  case.  When  ulitis  is 
circumscribed,  and  the  centre  of  the  trouble  seems  to  be  a  tooth 
filled  on  a  proximal  surface,  attention  may  be  first  directed  to  such 
a  condition.  Let  the  practitioner  take  a  strand  of  common  ligature 
silk,  and,  passing  it  between  the  teeth,  feel  if  it  runs  freely  about 
the  necks;  if  it  should  catch,  the  probability  is  he  has  discovered 
the  trouble. 

The  too  free  use  of  arsenical  paste  in  the  destruction  of  the  dental 
pulp  is  a  frequent  source  of  ulitis.  I  have  seen  two  or  three  very 
severe  cases  from  such  a  cause.  In  the  use  of  this  remedy,  it  is  in 
every  instance  well  to  cover  it  in  the  cavity  with  a  particle  of  wax, 
or,  where  this  is  not  admissible  (and  there  are  certainly  many  cases 
where  it  is  quite  impossible),  then  a  tuft  of  cotton,  saturated  with 
gum  sandarac,  is  placed  over  the  application,  and  protected  for  a 
few  moments  until  it  hardens.  (See  Odontalgia.)  In  inflamma- 
tion from  this  cause  the  immediate  local  use  of  the  sesquioxide  of 
iron  has  been  recommended  ;  but,  personally,  I  have  seen  no  good 
results  from  it,  the   harm  being  done   before  the  patient  applies. 

acid  or  creasote,  but  recommends,  based  upon  experiments  with  rabbits  made 
by  himself  and  Ummethun,  the  saccharate  of  lime,  the  alkaline  earth  com- 
bining with  the  carbolic  acid  to  form  a  non-irritating  salt.  Lime-water  is 
less  adapted  to  this  purpose,  owing  to  the  sparing  solubility  of  lime  in  water, 
and  the  large  quantity  of  lime-water  required  for  neutralizing  the  poison. 
Precipitated  carbonate  of  lime  does  not  combine  with  carbolic  acid,  but  may 
be  employed  in  case  the  saccharate  of  lime  should  not  be  procurable  at  once ; 
the  carbonate  appears  to  act  merely  mechanically  by  absorbing  the  poison, 
and  thus  delaying  its  ill  efl'ects ;  sufficient  time  is  thereby  afforded  to  prepare 
the  saccharate." 


542  ORAL  DISEASES  AND   SURGERY. 

Syringing  the  parts  thoroughly,  and  a  treatment  directed  on  general 
principles,  is  all  that  can  be  done. 

Brushes  used  in  cleansing  the  teeth  are  frequently  a  source  of 
offense  from  their  excessive  stiffness,  really  tearing  the  epithelium,  at 
each  cleansing,  from  the  mucous  membrane ;  the  patient  complains 
of  the  soreness  and  bleeding  of  the  gums  every  time  the  teeth  are 
brushed,  yet  seems  to  fail  to  recognize  that  he  himself  produces 
the  trouble. 

9.  Im2:)roj)erly  inserted  Artificial  Teeth.  —  Ulitis,  resulting  in 
fungoid  degeneration,  and  in  the  most  troublesome  of  chronic  condi- 
tions, is  frequently  witnessed  as  the  result  of  ill-adapted  dentures 
and  of  unsuitable  material  employed  in  their  construction.  Teeth 
inserted  on  plates  held  in  position  by  clasps  or  bands  attached  to 
certain  teeth,  are  a  prolific  source  of  offense.  Where  the  bearings 
of  a  plate  are  not  accurate,  the  bands  cut  into  the  gum  fret  and 
irritate  them,  until,  in  the  end,  the  teeth  to  which  the  clasps  are 
attached  are  loosened,  and  the  gum  passes  to  a  chronic  degeneracy, 
and  puffs  up,  losing  much  of  its  vitality;  otherwise  a  hypertrophied 
ring  of  the  tissue,  hard  and  callous,  surrounds  the  diseased  tooth, 
and  serves  as  a  sort  of  protection  to  the  adjoining  parts.  A  case  just 
now  comes  to  my  mind  in  which  a  lady,  wearing  an  upper  set  of 
teeth,  supported  partially  by  atmospheric  pressure  and  partly  by  a 
band  passing  around  the  only  natural  tooth  in  her  mouth,  had  pro- 
voked, in  this  socket,  an  epulic  growth  of  such  threatening  charac- 
ter that,  failing  to  cure  it  by  ordinary  means,  I  felt  compelled  to 
advise  an  operation  as  the  only  hope  of  saving  her  life.  Epithelioma 
I  have  also  seen  located  by  a  similar  cause;  having  had,  in  my 
own  practice,  the  misfortune  to  lose  one  such  case.  In  Mr.  Heath's 
Jacksonian  prize  essay,  drawings  are  given  of  certain  papular  hyper- 
trophies (thought  by  the  author  to  be  quite  rare  specimens)  on  the 
oral  mucous  membrane.  These  hypertrophies  I  have  frequently 
seen  on  the  membrane  beneath  the  cavities  of  suction  plates;  they 
look  like  enlarged  and  indurated  fungiform  papillae.  Another  form 
of  such  hypertrophy  is  induration  of  the  membrane  in  full,  lying 
beneath  the  cavity ;  the  parts  are  raised  by  sub-effusions,  which 
organize  and  become  as  hard  almost  as  cartilage.  Still  another 
form  is  the  rugose, — several  wheals  running  across  the  space ;  these 
indurations  I  have  never  known  to  do  any  harm.  In  some  instances 
they  remain  permanent  after  the  removal  of  the  offense ;  but,  as  a 
rule,  they  will  be  found  to  disappear  in  a  ^qw  months  after  a  plate 
is  taken  away:  indeed,  I  met  one  lady  having  these  hypertrophied 


THE   GUMS  AND    THEIR   DISEASES. 


543 


papillae,  who  told  me  she  had  had  them  for  over  a  year,  and  had 
never  ceased  to  wear  her  plate. 

Hypertrophy  of  the  gum  in  mass  occasionally  results  from  the 
mechanical  irritation  of  dental  plates.  I  am,  at  the  time  of  writing 
this,  treating  a  lady  suffering  under  such  an  enlargement ;  the  trouble 
is  in  the  upper  gums,  and  they  seem  like  thickened  masses  of  gristle, 
and,  I  am  sorry  to  say,  prove  about  as  insensible  to  medical 
impression. 

Vulcanite,  a  material  much  employed  in  the  construction  of  dental 
plates,  is  to  many  mouths  a  source  of  unbearable  offense.  The 
cases  that  have  come  under  my  own  observation  have  been  all  alike, 
—soft,  flabb}^  relaxed,  congested,  and  very  sluggish  in  recuperation, 
the  gum  tissue  seeming  to  be  softened  from  surface  to  base.  Acid 
and  astringent  lotions  are  best  adapted  to  the  cure. 

Silver  is  another  material  that  it  would  perhaps  be  as  well  to 
dispense  with  in  the  construction  of  dental  appliances;  also  gold 
too  much  alloyed  with  copper,  running  down,  as  it  is  sometimes 
found,  to  fourteen  carats. 

10  and  11.  In  other  parts  of  this  work  occasion  is  taken  to  treat, 
under  what  are  deemed  to  be  proper  heads,  various  conditions,  com- 
monly associated  under  the  common  appellation  of  gum  diseases, 
as,  for  example,  the  epulic  growths,  considered  in  a  succeeding 
chapter. 

Observation  of  Fig.  224  exhibits  a  congestion  which  has  swollen 
the  gums  and  tissues  of  the  hard  palate  to  an  extent  which  conceals 

Fig.  224. — View  of  Gums  Inplamed  by  Vulcanite   Plate. 


almost  completely  three  posterior  teeth  which  remain  in  the  parts. 
The  patient  from  whose  mouth  the  drawing  was  made  had  worn  a 
plate  of  vulcanite  nine  months  ;  the  parts  were  a  dusky  red, — flabby, 


% 


544  ORAL  DISEASES  AND   SURGERY. 

relaxed,  and  exceedingly  indolent.  There  was  no  particular  com- 
plaint of  pain, — simply  a  soreness,  togetiier  with  a  tenderness  on 
pressure,  which  tenderness  had  increased  gradually  until  the  removal 
of  the  piece  became  a  necessity.  The  cause  of  irritation  from  these 
plates  is  variously  considered  :  the  most  likely,  however,  is  the  very 
complete  exclusion  of  atmospheric  air,  and  the  consequent  heating 
which  follows.  To  cure  such  cases  it  will  be  found,  in  most  in- 
stances, a  necessity  to  remove  the  denture,  after  which  stimulating 
and  astringent  gargles  may  be  prescribed. 
A  very  excellent  combination  is  as  follows : 

K. — Aquse  Colonise,  sj ; 

Tincturae  capsici  corapositae,  5j ; 
Sodfe  biboratis,  5'j ; 
Tincturce  cinchome, 
Tincturae  pyrethri,  fi,a  sj ; 
Aquje,  gvj,     M. 

A  second  application,  which  justly  receives  much  commendation, 
is  the  following : 

R. — Aluminis  sulphatis,  gr.  x  ; 
Acidi  tannici,  gr.  xx; 
Glycerime,  ^j.     M. 
To  be  brushed  over  the  parts. 

Cases  of  hypertrophy  from  ill-fitting  clasps  or  ill-fitting  plates  are 
not  unfrequently  met  with  ;  sometimes  such  an  induration  will  be 
found  circumscribing  a  single  tooth  to  an  extent  which  half  conceals 
it,  the  band  being  accommodated  in  a  space  existing  between  the 
gum  and  tooth.  I  h'ave  known  such  cases  to  give  much  concern  by 
the  obstinacy  of  their  persistence  after  the  removal  of  the  cause  of 
offense;  but  such  anxiety  is  seldom  well  founded,  for  even  should 
the  induration  remain  it  will  exhibit  no  tendency  to  degenerate.  In 
the  treatment  it  is  only  desirable  to  remove  the  offending  baud,  and 
leave  the  case  to  nature. 

As  general  hypertrophy  of  the  gums  is  concerned,  I  might  iHus- 
trate  the  condition  by  referring  to  a  ca.se  at  present  under  treatment. 
The  patient,  a  lady  in  fine  liealth,  middle-aged,  wears  a  plate  of  gold 
containing  seven  scattered  tecih.  Wherever  this  plate  bears,  the 
parts  are  enlarged,  indurated,  and  scirrhus-like.  If  it  were  not  for 
the  absence  of  the  associate  expressions  of  carcinoma,  one  might 


THE   GUMS  AND    THEIR  DISEASES.  545 

very  readily  infer  the  presence  of  such  disease.  The  explanation  of 
such  induration  is  to  be  found  in  an  imperfect  adaptation  of  the 
denture,  conjoined,  perhaps,  with  a  cachexia.  The  treatment  has 
been  the  very  simple  one  of  advising  the  patient  not  to  wear  the 
plate,  nor  any  other,  until  a  cure  is  obtained.  No  medication  has 
been  deemed  necessary. 

Still  another  class  of  cases  exists  in  the  hypertrophy  of  the 
mucous  membrane  lying  beneath  the  surface  of  suction  cavities. 
Sometimes  this  surface  will  be  found  simply  thickened  and  hard- 
ened;  at  other  times  it  will  be  seen  broken  into  deep  fissures ;  still 
again  it  is  observed  studded  with  papillae,  fungiform  in  character, 
and  not  unfrequently  possessed  of  a  tendency  to  hemorrhage.  I 
have  met  with  these  various  cases  where  quite  serious  results 
seemed  threatened,  although  never  except  in  a  single  one  did  any 
ill  consequences  ensue.  In  this  one  case  necrosis  of  the  underlying 
bone  exposed  the  nares. 

Treatment. — This  is  generally  to  be  tentative ;  the  plate  must 
be  removed,  or  at  least  the  suction  cavity  must.  If  the  parts  do  not 
recover  after  such  removal  of  the  offense,  it  may  be  found  desirable 
to  touch  Avith  zinc,  iodine,  or  capsicum.  If  caries  or  necrosis 
should  ensue,  such  condition  is  to  be  treated  as  referred  to  in  the 
chapter  on  these  diseases. 

Fig.  225  exhibits  a  form  of  general  hypertrophy  of  the  gum  struc- 
ture occasionally  to  be  met  with.     Such  conditions  are  oftentimes 
found  to  be  but  expressions  of  unobserved 
local  agents  of  oflFense,  upon  the  removal  ■^^'^-  '^-^■ 

of  which  the  overgrowth  will  disappear. 
Where,  on  the  contrary,  the  hypertrophy  is 
seen  to  be  an  expression  of  a  constitutional 
condition,  the  observable  vice  is  to  be  cor- 
rected. The  best  local  treatment  consi.sts 
in  frequent  incisions  through  the  parts, 
and  the  application  of  tincture  of  iodine. 
Kemoval  of  the  overgrowth   by  the  knife 

■IT  .»  /•  1     i        1  View  of  Case  of  General  Hvper- 

is   seldom,  if  ever,  found   to    be   compen-  troph? 

sating. 

Fig.  226,  a  case  of  chronic  ulitis,  wi^h  recession,  is  a  type  of  a 
very  common  condition,  and  has  a  great  variety  of  meanings.  The 
principal  cause  of  such  recession  is  found,  according  to  my  own 
experience,  in  the  accumulation  of  small  quantities  of  tartar  just 
below  the  free  edge  of  the  gums.     A  second  cause,  and  a  very 

35 


546 


ORAL  DISEASES  AND  SURGERY. 


prominent  one,  lies  in  a  solidification  of  the  tooth  structure, — the 
equilibrium  of  circulation  existing  between  the  tooth  pulp,  periodon- 
teum,  and  gum  being  thus  disturbed.  Causes  strictly  local,  how- 
ever, need  only  give  concern,  as  they  affect  the  appearance  of  the  parts 
and  the  health  of  the  teeth  ;  they  are  susceptible  of  remedy,  re- 
quiring only  attention  and  the  proper  skill.  It  will  be  readily 
inferred,  however,  from  what  has  been  said  on  previous  pages,  that 
local  lesions  are  not  alone  to  blame  for  such  conditions.  "  In  forming 
a  judgment,"  says  Mr.  Bell,  "upon  cases  of  this  description,  and  even 
upon  those  in  which  the  loss  of  substance  is  associated  with  more 
or  less  of  diseased  action,  it  is  necessarv  to  recollect  that  the  teeth 


Fio   220. — View  of  Chronic  Ulitis,  with  Kecession. 


in  old  age  are  removed  by  this  identical  process, — namely,  the 
destruction  of  their  support  by  the  absorption  of  the  gums  and 
alveolar  processes ;  and  as  this  step  toward  general  decay  com- 
mences at  very  different  periods  in  different  constitutions,  it  may, 
doubtless,  in  many  cases,  even  in  persons  not  beyond  the  middle 
period  of  life,  be  considered  as  an  indication  of  a  sort  of  premature 
old  age,  or  an  anticipation  at  least  of  senile  decay,  as  far  as  regards 
these  parts  of  the  body." 

In  depressed  conditions  of  the  life-force,  as  witnessed  in  the. 
habitual  drinker  and  debauchee,  such  recession  is  generally  found 
conjoined  with  suppuration,  and  affects  all  the  parts  alike;  the  gums 
are  turgid,  sluggish-looking,  and  more  or  less  purple ;  the  mucous 


THE   GUMS  AND    THEIR  DISEASES.  547 

membrane  lining  the  mouth  and  throat  is  of  a  dirty  red ;  the  tremor 
and  prostration  of  the  system  at  large  show  the  constitutional 
nature  of  the  offense. 

Another  form  of  this  recession  is  associated  with  the  sickly  and  . 
weak  ;  here,  however,  the  part  is  even  lighter  than  in  health,  is 
shriveled  and  shrunken,  clasping  the  neqk  of  the  tooth  tightly  and 
closeh^, — seeming,  indeed,  shrinking  within  itself.  These  eases  are 
always  anagmic,  being  found  usually  in  the  female  sex,  or  in  males 
inclining  to  phthisis.  Everything  that  tends  to  induce  such  a  con- 
dition may  be  regarded  as  a  predisposing  cause  :  such  are  bilious 
and  inflammatory  fevers,  the  excessive  use  of  mercurial  medicines, 
the  venereal  virus,  anything  tending  to  the  deterioration  of  the 
fluids  of  the  body.  Persons  of  cachectic  habit  are  far  more  subject 
to  it,  and  generally  in  its  worse  forms,  than  individuals  in  the  en- 
joyment of  good  health.  Because  of  the  truthfulness  of  such 
assumptions  it  is  seen  that  the  condition  is  an  occasion  of  warning. 
Tn  my  own  experience,  I  have  not  unfrequently  recognized  that  such 
a  recession  of  the  gums  was  a  first  indication  of  declining  health. 

Treatment. — This  is  of  course  to  be  directed  to  the  cause.  Where 
this  shall  be  found  to  be  of  a  strictly  local  nature,  most  excellent 
effects  are  occasionally  secured  by  scarifying  the  affected  gums  three 
or  four  times  a  week,  and  touching  them  lightly  with  chloride  of 
zinc,  a  solution  in  strength  of  about  grs.  xx  to  water  5j.  Some- 
■llimes,  and  I  have  occasionally  succeeded  much  to  my  satisfaction, 
the  edges  may  be  pared  and  brought  together  with  a  single  stitch : 
this  little  operation,  however,  only  applies  where  the  tissues  are 
reasonably  loose  and  fairly  healthy,  and  the  recession  is  V-shaped. 
Compound  tincture  of  capsicum  is  an  excellent  provocative  of  gran- 
ulations ;  iodine  also  acts  happily.  The  parts  are  always  to  be 
scarified  to  allow  such  applications  to  be  of  any  service.  The  vari- 
ous washes  recommended  are,  of  course,  useful  or  not  so,  according 
as  they  may  be  adapted  to  the  peculiar  indications  :  of  these,  the 
stimulating  and  astringent  will  be  found  most  frequently  demanded. 
Where  the  teeth  are  thus  exposed  without  apparent  lesion,  either  of 
a  local  or  general  nature,  the  trouble  is  to  be  deemed  incurable. 

Congenital  Union  of  Gums. — Dr.  W.  S.  Carter  reports  the  follow- 
ing anomalous  case,  which,  with  a  few  others,  is  presented  as  an 
interesting  study  in  this  direction  of  oral  troubles:  "Mrs.  W.  was 
delivered,  after  an  easy  labor  at  full  term,  of  a  living  male  child. 
The  infant  was  perfectly  quiet  for  a  few  moments  after  its  birth,  and 
then  spasmodic  respiratory  efforts  were  made.     Thinking  the  throat 


548  ORAL  DISEASES  AND  SUttGERY. 

might  be  obstructed  by  mucus,  I  endeavored  to  introduce  my  finger 
to  remove  it.  The  finger  passed  readily  between  the  lips,  but,  to  my 
astonishment,  I  could  get  it  no  further  than  the  gums,  which  both  by 
sight  and  touch  I  found  firmly  united. 

"As  it  was  necessary  to  act  promptly,  I  immediately,  with  the 
assistance  of  my  partner,  Dr.  Tilford,  divided  the  tissue  uniting  the 
gums.  This  appeared  to  be  about  as  thick  as  the  gums,  and  was 
cartilaginous,  extending  as  far  back  on  either  side  as  the  angle  of  the 
jaw.  Notwithstanding  this  free  division,  which  enabled  the  child  to 
breathe  with  more  facility,  the  jaws  Avere  immovable. 

"After  letting  the  patient  rest  a  few  hours.  Dr.  Sellers,  of  Browns- 
burg,  visited  the  patient  with  me ;  and  it  w^as  decided  to  use  some 
force  to  separate  the  jaws,  and  make  a  further  careful  exploration. 
This  exploration  showed  us  a  tough  membrane,  one-eighth  of  an  inch 
in  thickness,  passing  from  the  palate  bone  above,  and  inserted  into 
the  lower  gum.  Upon  the  division  of  this  and  the  use  of  some  little 
force,  the  jaws  were  separated. 

"  In  two  weeks  the  gums  had  healed,  the  child  took  nourishment 
readily,  and  was  doing  well. 

"  Other  malformations  also  existed  in  this  case:  viz.,  the  fingers 
and  toes  were  webbed,  and  the  ears  were  in  rather  a  rudimentary 
condition — the  integument  passing  from  the  head  over  the  anterior 
surface  of  the  upper  third  of  each  of  these. 

"  When  the  mother  was  about  three  months  pregnant,  her  son, 
about  six  years  of  age,  had  a  severe  convulsion,  the  jaws  being  spas- 
modically closed.  She  was  alone  at  the  time,  and  her  terror  was 
excessive ;  and,  indeed,  since  then,  during  all  the  remaining  months 
of  her  pregnancy  she  states  the  frightful  scene  has  scarcely  ever 
been  absent  from  her  mind." 

"  We  have  delayed,"  remarks  the  editor  in  whose  journal  this  in- 
teresting communication  appears,  "for  some  weeks  the  publication  of 
Dr.  Carter's  extraordinary  case,  in  order  that  we  might,  if  possible, 
find  recorded  some  similar  cases  or  case  ;  but  after  a  diligent  search 
"we  have  been  utterly  disappointed.  Even  Saint-Hilaire,  to  whose 
study  of  the  various  anomalies  of  organization  science  is  so  greatly 
indebted,  fails  us  in  presenting  any  analogous  instance. 

"  While  almost  any  one  of  the  external  openings  of  the  body  may 
be  imperforate,  yet  this  condition  much  ofteuer  afifects  the  inferior 
than  the  superior  orifices  of  the  trunk:  e.g.  closure  of  the  anus  as  a 
congenital  condition  is  more  frequently  met  with  than  closure  of  the 
eyelids,  closure  of  the  vagina  than  of  the  external  auditory  meatus. 


THE   GUMS  AND    THEIR  DISEASES.  549 

"  In  regard  to  congenital  adhesions  of  the  mouth  hitherto  de- 
scribed, they  have  been  from  adherence,  sometimes  complete,  in 
other  instances  partial,  of  the  lips.  Even  this  malformation  the 
illifstrious  Bo3^er  spoke  of  as  a  possibility,  never  having  seen  it;  but 
Velpeau  discovered  that  Haller  had  pointed  out  its  occurrence  in  the 
huniau  species  and  also  in  the  inferior  animals,  that  Schenkius  had 
met  with  cases  upon  which  he  had  to  operate,  and  that  Desgenettes 
had  seen  a  seven  months'  foetus  with  imperforate  mouth. 

"  In  Saint-Hilaire's  work,  chapter  iii.,  Des  Anomalies  j^ar  Con- 
tinuite  des  Parties  ordinairement  disjointes,  section  i.,  Des  Anoma- 
lies par  Imperf oration,  will  be  found  the  following,  which  may  be 
of  some  interest  in  connection  with  Dr.  Carter's  report:  The  imper- 
foration  of  the  nares  is  much  less  frequent  than  that  of  the  eyelids; 
nevertheless,  Littre  and  Jean  Bianchi  have  seen  it  in  sulyects  in 
whom  other  irregularities  also  were  found,  and  Oberteuffer  has  also 
several  times  observed  the  same  condition. 

"In  the  case  mentioned  by  Littre,  the  closure  of  the  nares  was 
complicated  with  closure  of  the  mouth,  the  skin  passing  over  both 
apertures,  an  anomaly  of  still  less  frequent  occurrence.  The  closure 
of  the  mouth  has  also  been  seen  where  the  nares  were  unobstructed, 
but  these  cases  presented  various  other  deviations  also. 

"  As  to  the  possible  influence  of  the  sudden  and  severe  terror  to 
which  the  mother  was  subjected,  which  Dr.  Carter  mentions,  in 
causing  the  malformation,  it  probably  is  better  neither  to  affirm  nor 
still  less  to  deny.  Certain  it  is  that  the  tendency  of  the  observant 
and  thoughtful  in  our  profession  is  not  to  reject  as  '  old  wives'  fables' 
all  that  is  told  us  of  the  very  strong  influence  of  maternal  impres- 
sions upon  the  foetus,  fables  which  have  so  long  found  such  genera 
credence  with  mothers  and  with  the  public.  Those  who  are  inter- 
ested in  the  study  of  this  question  will  find  an  admirable  and  philo- 
sophic discussion  of  it,  by  Dr.  Alfred  Meadows,  in  the  seventh 
volume  of  the  London  Obstetrical  Society's  Transactions.  It  occurs 
in  connection  with  the  report  of  a  case  of  Monstrosity,  given  by 
Dr.  M.,  the  motlier  attributing  the  deformities  of  her  off'spring  to 
the  fact  that  during  the  earlier  weeks  of  her  pregnancy  she  was 
greatly  horrified  by  being  shown  some  of  Aristotle's  plates,  in  which 
were  exhibited  some  deformities  resembling  this,  and  specimens  of 
other  monstrosities." — Western  Journal  of  Medicine. 

"  Stomatitis  and  Pharyngitis  Leuceemica. — In  Virchow''s  Ar- 
chives, Dr.  F.  Mosler  relates  the  case  of  a  male  forty  3'ears  old,  and 
previously  of  sound  health,  in  whom,  in  the  course  of  some  fifteen 


550  OBAL  DISEASES  AND  SURGERY. 

months,  there  took  place  gradually  a  swelliug  of  the  glands  on  both 
sides  of  the  throat,  attended  with  inflammation  of  the  mucous  mem- 
brane of  the  mouth  and  pharynx,  with  flaccidity  of  and  hemorrhage 
from  the  gums,  followed  by  swelling  of  the  axillary  and  inguinal 
glands,  and  finally  of  the  liver  and  spleen.  There  was  now  an 
evident  increase  in  the  white  particles  of  the  blood.  In  the  case 
described,  the  only  etiological  agent  to  which  the  morbid  phenomena 
it  presented  could  be  referred  was  inordinate  exertion  of  mind  and 
body.  The  condition  of  the  throat  was  of  especial  interest.  Its 
mucous  membrane  was  red  and  swollen,  and  oyer  its  surface  there 
were  spread  numerous  medullary  elevations  having  a  smooth 
shining  appearance.  Both  tonsils  were  enlarged,  and  their  surfaces 
presented  the  appearance  of  a  congeries  of  large,  dense,  medullary 
knots.  The  secretions  of  the  surface  of  the  mouth  and  larynx  and 
of  the  salivary  glands  were  greatly  increased  by  talking.  After  a 
thorough  rinsing  of  the  mouth,  its  secretions  gave  an  acid  reaction. 
The  patient  had  not  suffered  previouslv  from  any  disease  of  the 
month  or  throat.  The  patient  was  attacked  with  this  only  after  the 
lymphatic  glands  of  the  neck  had  become  enlarged,  and,  at  first, 
with  their  increase  or  diminution  the  throat  affection  became  worse 
or  better.  Finally,  under  the  use  of  quinia  and  iron,  remedies 
which  exerted  a  beneficial  influence  on  the  entire  morbid  phenomena, 
the  patient  got  well.  Dr.  M.  believes  that  the  form  of  stomatitis 
and  pharyngitis  here  described  is  a  specific  disease  resulting  from  a 
leucaemic  dyscrasy.  The  inflammation  of  the  mouth,  which  in  its 
symptoms  had  a  close  resemblance  to  scorbutic  stomatitis,  was 
probably  caused  by  an  irritation  due  to  some  morbid  chemical  product 
in  the  blood  and  the  secretions  of  the  lymphatic  glands,  by  which, 
also,  according  to  Dr.  M.,  is  to  be  explained  the  affection  of  the 
mouth  met  with  in  cases  of  diabetes,  the  nature  of  which  is  still, 
however,  unknown." 

"  Blue  Line  in  Saturnine  Affections,  and  its  Pathognomonic 
Value.  (Archives  de  Medecine  Navale,  and  Gazette  Hebdomadaire.) 
— Dr.  Falot  refutes  the  authors  who  believe  that  the  blue  line  along 
the  gums  is  formed  by  an  accidental  deposit  on  the  buccal  mucous 
membrane  of  lead  furnished  by  dust  contained  in  the  air  or  food,  or 
still  more  in  fluids  that  have  been  adulterated  or  accidentally  charged. 
According  to  M.  Grisolle,  among  others,  the  blue  line  is  the  livery 
of  the  lead-worker,  not  a  symptom  of  poi.'^oning,  but  a  simple 
deposit,  and  a  sign  of  the  worker's  occujtation.  M.  Falot  quotes 
the  observations  of  Beau,  Barlow,  Gregory  Smith,  and  Lecoq,  all 


THE   GUMS  AND    THEIR   DISEASES.  551 

of  whom  observed  the  blue  line  in  patients  undergoing  an  internal 
treatment  with  pills  of  subearbonate  or  acetate  of  lead;  and  he 
gives,  in  addition,  the  reports  of  some  cases  of  his  own,  which  were 
gathered  in  an  epidemic  of  colic  in  a  ship's  crew  at  the  Gaboon,  the 
cause  of  which  was  lead-poisoning.  Finally,  after  having  estab- 
lished by  experiment  the  impossibility  of  reproducing  the  blue  line 
artificially  by  touching  the  gums  corresponding  to  the  incisor  and 
canine  teeth  of  the  lower  jaw  with  a  brush  dipped  in  acetate  of 
lead,  and  after  having  proved  that  oxygenated  water,  and  water 
sharpened  by  sulphuric  acid,  the  ordinary  reagents  of  lead,  had  no 
influence  upon  the  blue  line  when  it  is  plainly  established,  Dr.  Falot 
proves  that  the  line  is  the  result  of  an  elimination  of  the  lead,  and 
indicates  by  its  manifestation  that  the  lead,  carried  along  by  the 
circulation,  comes  to  be  deposited  in  the  tissue  of  the  gums,  where 
it  forms  a  combination  which  reveals  its  presence  by  a  more  or  less 
intense  blue  coloration.  M.  Falot  finishes  his  contribution  by 
representing  the  blue  line  as  a  sign  of  penetration  of  lead  into  the 
economy,  and  he  derives  the  important  conclusion  for  forensic 
medicine,  that  its  presence  may  denote  lead-poisoning,  although  an 
analysis  of  the  viscera  may  not  have  revealed  the  smallest  trace  of 
the  metal." 


CHAPTER    XXYII. 

CARIES    OF    THE    MAXILLA. 

Caries  of  bone,  practically  viewed,  is  a  disease  very  analogous 
to  ulceration  in  the  soft  parts,  and  is  possessed  of  the  threefold  ex- 
pression of  simple,  strumous,  and  specific*     As  the  jaws  are  con- 


*  "  There  was  a  time  when  the  conception  of  caries  was  very  comprehen- 
sive. Wherever,  by  pathological  changes,  a  corroded,  disorganized  condi- 
tion of  bone  had  been  occasioned,  the  term  caries  was  applied  ;  in  this  sense 
we  might  speak  of  cancerous  and  sj-philitic  caries,  we  might  term  the  de- 
ficiencies of  bone  caused  by  aneurisms  caries,  etc.  At  present  we  confine 
ourselves  more  and  more  to  so  naming  two  forms  of  actual  ulceration  of  bone, 
the  one  simple,  the  other  fungous  caries.  Simple  caries  corresponds  to  what, 
upon  the  skin,  we  would  call  an  indolent  ulcer, — a  loss  of  substance  at  the 
surface  of  a  bone,  slowly  going  deeper,  upon  the  whole,  however,  shallow, 
upon  whose  base  small  amounts  of  pus,  together  with  breaking-down  remains 
of  tissue,  are  continually  separated.  The  pus,  as  in  general  all  fluid  con- 
stituents of  the  secretion,  is  produced  by  the  exposed  medullary  tissue.  This, 
at  a  certain  distance  from  the  surface,  is  in  a  hj-pertemic,  hyperplastic  con- 
dition, which,  toward  the  surface,  gives  place  to  an  extraordinarily  dense 
cellular  infiltration.  The  cells  fill  up  all  the  pores  of  the  osseous  structure  com- 
pletely :  they  leave  no  space  for  blood  and  blood-vessels  ;  the  latter  are  com- 
pressed, and  then  together  witli  the  cells  themselves  go  over  into  a  molecular 
detritus.  The  latter  not  unfrequently  forms  an  uninterrupted,  most  super- 
ficial layer,  which  naturally  only  obtains  support  and  adheres  because  it  is 
penetrated  by  the  trabeculse  of  the  spongy  substances  not  yet  destroyed  and 
connected  net-formed.  The  interference  of  the  osseous  tissue  in  the  inflam- 
matory process  has  consequently  a  decidedly  injurious  influence  upon  its 
course.  It  is  the  osseous  tissue  which,  upon  the  one  hand,  by  refusing  space, 
makes  impossible  the  free  development  of  a  healthy  granulating  surface  and 
lets  the  cell-formation  smother  in  its  over-exuberance  ;  upon  the  other  hand, 
however,  by  the  persistent  connection  with  the  health}'  bony  trabecule  of  the 
deeper  layers,  holds  fast  the  breaking-down,  putrefactive  material,  which  had 
better  have  been  separated  and  cast  oft"  long  ago,  like  a  slough  upon  the  sur- 
face of  an  ulcer,  and  thereby  impress  upon  the  entire  process  the  character  of 
an  indolent  ulceration." — Eindfleisch. 

"  Chronic  ostitis  or  caries  is  a  chronic  inflammation  of  the  connective  tissue 
in  the  bone,  with  consumption  of  the  latter.  If  from  a  carious  spot  we 
(552) 


CARIES  OF  THE  M AXILLA.  553 

cerned,  the  condition  is  confined  almost  exclusively  to  the  superior 
bones.  The  causes  which  act  as  provocatives  are,  qf  course,  various; 
yet  dead  teeth  and  roots  of  teeth  will  be  found  far  to  preponderate. 

remove  a  particle  of  bone  and  look  at  it  under  the  microscope,  we  will  in 
many  cases  see  its  edges  and  surface  bitten  out,  as  it  were ;  the  bone-corpus- 
cles being  unchanged;  the  intercellular  substance  somewhat  more  cloudy 
than  usual,  perhaps,  but  not  much  altered.  A  section  of  bone  taken  from 
the  vicinity  of  such  a  carious  spot,  shows  nothing  different.  If  we  saw  or 
cut  out  a  piece  from  a  carious  spot  and  abstract  the  chalky  salts  from  the 
bone  by  chromic  acid,  and  then  make  section  through  it  and  clear  them  with 
glycerine,  we  will  see  these  bitings,  as  it  were,  quite  regularly  along  the 
edges,  with  young  neoplasia  growing  into  the  defects,  while  able  to  observe 
that  the  further  increase  of  them  goes  hand-in-hand  with  the  dissolution  of 
the  bone  ;  the  bone-corpuscles  are  unchanged,  no  destruction  starts  from 
them.  We  occasionally  see  them  half  destroyed  at  the  edge  of  a  piece  of 
the  bone.  "What  becomes  of  the  cells  that  were  in  them,  we  can  hardly  say; 
they  can  no  longer  be  recognized  among  the  numerous  young  cells  of  the 
inflammatoi'y  new  formation  among  which  they  enter :  it  is  possible  that,  freed 
from  their  cage,  they  aid  in  increasing  the  cell-brood  by  subdividing;  possi- 
bly they  die;  at  all  events,  so  far  as  may  be  judged  by  the  change  of  form, 
they  do  not  aid  in  dissolving  the  bone.  But  how  the  bone  is  dissolved  remains 
an  unsolved  riddle. 

"  One  point,  however,  we  must  consider.  It  would  be  very  supposable  that 
the  bone-substance,  having  its  nutrition  atfec ted,  would  begin  to  break  up  and 
crumble  into  very  fine  particles  or  powder ;  this  would  be  especially  apt  to 
occur  if  the  bone  had  previously  lost  its  organic  substance.  It  could  even 
be  shown  that  this  is  the  primary  step  in  ulceration  of  the  bone  or  caries,  and 
those  who.  regard  destruction  of  tissue  as  the  primary  step  in  ulcers  of  the 
soft  parts,  and  inflammatory  new  formations  on  the  second,  will  also  hold 
this  view  in  regard  to  bone.  Observation,  however,  speaks  very  decidedly 
against  the  universality  of  this  view  of  ulceration,  for  what  is  not  found 
proven  as  concerns  the  soft  parts,  cannot  be  considered  true  as  regards  the 
bones.  But  there  is  no  doubt  that  portions  of  bone  may  crumble  off,  and, 
when  there  is  suppurative  ostitis,  these  small  particles  of  bone  may  be  found 
in  the  pus.  This  would  be  a  necrosis  of  the  lowest  form ;  such  a  death  of 
the  particles  of  tissue  also  occurs  in  the  soft  parts,  both  in  acute  and  chronic 
inflammation.  It  cannot  be  considered  as  a  rule  in  caries:  it  is  only  seen 
occasionally  in  caries  with  suppuration  or  caseous  degeneration.  Here  even 
large  portions  of  bone  may  actually  become  necrosed,  and  for  this  combina- 
tion of  caries  and  necrosis  we  have  the  curious  name  caries  necToilca. 

"  In  the  soft  parts  is  to  be  seen  the  development  of  the  process  of  ulceration 
in  a  fungous  ulcer  when  the  productive  character  predominates.  This  has  its 
analogy  in  bone,  in  ostitis  fnngosa,  where  there  is  yet  no  destruction  of  the 
inflammatory  new  formation,  but  where  interstitial  granulative  tissue  has 
grown  all  through  the  bone.  If  one  remembers  the  atonic,  torpid  ulcer  of 
the  soft  parts,  and  recalls  how  the  neoplasm  rapidly  breaks  down  into  pus, 


554  ORAL  DISEASES  AND  SURGERY. 

Caries  of  the  jaw  presents  commonly,  yet  it  may  be  in  aggravated 
form,  the  external  features  which  characterize  the  ordinary  alveolar 
abscess,  whether  in  its  acute  or  chronic  forms.  This,  however, 
would  be  inferred,  such  lesion  being  so  commonly  its  origin.  When 
the  attack  is  acute  in  its  nature,  ulitis  or  periostitis  will  always  be 
found  associated  with  it.  If  the  disease  originates  as  a  pure  ostitis, 
then  the  gum  in  turn  quickly  sympathizes;  if,  on  the  contrary,  the 
inflammation  arises  from  a  tooth,  periodontitis  Avill  distinguish  the 
offending  agent.  In  all  inflammations  about  these  parts,  whatever 
their  character  and  cause,  the  abortive  treatment  cannot  too  quickly 
be  attempted.  From  failure  to  attack  with  sufficient  vigor  such  in- 
flammations, I  have  not  unfrequently  known  the  whole  bone  to  be 
destroj^ed. 

Caries  once  established,  a  diagnosis  is  made  easy  through  the  in- 
strumentality of  the  sense  of  touch.  One  or  more  fistulous  openings 
will  be  found  to  exist  in  the  gum,  or  it  may  be  in  some  neighboring 
part,  the  orifices  of  which  are  surrounded  commonly  by  fungous 
granulations ;  through  these  sinuses  it  is  only  necessary  to  carry  a 
probe,  when  the  bone  is  found  riddled,  honeycomb-like,  and  easy  to 
break  down,  either  as  the  surface  is  implicated,  or  as  in  the  stru- 
mous expression  of  the  disease  the  deeper  parts  are  involved.  In 
such  examinations  it  will  always  be  found  advantageous  to  replace 
the  ordinary  probe  with  the  common  dental  excavator,  as  otherwise, 
from  the  less  accurate  touch  attained  through  the  first  instrument, 
it  is  possible  to  mistake  the  denuded  bone  of  ordinary  alveolar 
abscess  for  the  more  formidable  and  extensive  disease,  thus  being 
misled  as  to  the  treatment  required.  In  carrying  the  instrument 
through  the  opening  of  an  alveolar  abscess,  it  is  remarked  that  the 
bone  is  denuded ;  but  the  touch  differs  from  that  peculiar  to  caries, 
in  the  fact  of  this  denuded  bone  being  hard  and  resisting.  Not 
always,  however ;  for  it  has  just  been  remarked  that  periodontitis 

undergoes  caseous  transformation  or  disintegrates,  and  simply  applies  the 
same  change  to  bone,  he  will  readily  understand  the  case  ;  this  also  gives 
caries  another  character.  There  are  very  torpid,  atonic  forms  of  caries  where 
the  neoplasia  causes  but  little  destruction  of  bone,  and  then  disintegrates  or 
undergoes  caseous  metamorphosis,  and  then  in  the  living  organism  there  is  a 
sort  of  maceration  of  the  diseased  bone  :  the  soft  parts  in  the  bone  suppurate. 
If  this  happens  before  the  bone  is  dissolved,  the  portion  of  bone  that  has 
suppurated  is  necrosed.  Here,  also,  most  of  the  fault  of  the  disintegration  is 
due  to  deficient  vitality.  But  we  must  look  to  constitutional  influence  why 
we  have  in  one  case  fungous  or  proliferating,  in  another  atonic  caries." — Bill- 
roth. 


GABIES  OF   THE  MAXILLA.  555 

and  alveolar  abscesses  are  the  most  common  causes  of  ostitis  and 
caries,  reference  being  had  only  to  the  pure,  uncomplicated  cases  of 
alveolar  abscess.  As  a  rule,  when  a  sharp  instrument  introduced 
can  be  made  to  pass  readily  into  the  substance  of  the  bone,  and  to 
break  it  down,  caries  is  present.  If,  on  the  contrary,  the  bone  is 
solid  and  resisting,  even  although  denuded,  caries  does  not  exist. 
Carious  bone  is  frequently,  however,  found  associated  with  exu- 
berant granulations,  which  deceive  when  the  probe  used  is  not  of 
sufficient  sharpness  readily  to  penetrate  the  fungus.  As  a  rule,  no 
harm  is  found  to  result  in  boldly  thrusting  knife  or  probe  through 
soft  parts  inferred  to  mark  maxillary  disease. 

An  ostitis,  however  provoked,  does  not  by  any  means  necessarily 
run  into  osseous  ulceration,  any  more  than  ulceration  is  necessarily 
a  result  of  an  inflammation  in  the  soft  parts.  There  ai'e,  however, 
certain  conditions  which  markedly  predispose  to  such  ulcerations : 
of  these  the  strumous  is  without  doubt  the  most  marked.  The 
bones  of  scrofulous  subjects  break  down  easily,  also  those  of  per- 
sons who  have  received  the  mercurial  impression.  Cancerous 
caries  of  the  upper  jaw  is  not  unfrequently  to  be  met  with  ;  while, 
aside  from  such  conditions,  it  has  seemed  to  my  experience  to  be 
true  that,  in  persons  of  the  most  robust  and  vigorous  health,  a 
slight  cause  has  been  sufficient  to  develop  the  disease.  A  case  this 
moment  recalled  (a  very  marked  one)  will  serve  to  illustrate  the 
probability. 

In  the  autumn  of  1867  a  gentleman  from  a  distant  State  visited 
Philadelphia  for  the  purpose  of  having  an  opinion  concerning  a 
fistule  that  existed  over  the  apex  of  the  right  upper  lateral  incisor 
tooth,  and  which  had  long  resisted  the  ordinary  applications  and 
injections  used  by  his  professional  adviser  at  home.  This  fistule  had 
originated  from  the  lateral  tooth,  which  was  a  dead  one,  and  was 
considered  simply  an  alveolar  abscess,  the  only  question  thought  to 
be  involved  being  the  loss  of  the  tooth,  which  the  patient  was  most 
desirous  to  save.  The  gentleman  coming  first  under  the  care  of  a 
personal  friend,  I  had  an  opportunity  to  see  him  in  consultation, 
when  examination  revealed  a  softened,  honeycomb-like  condition 
not  only  of  the  right  but  also  partially  of  the  left  jaw,  necessitating 
an  operation  of  very  extensive  character,  so  far  as  the  removal  of 
softened  bone  was  concerned. 

In  this  case  I  failed  to  recognize  anything  wrong  with  the  general 
health  of  the  patient,  in  which  opinion  I  was  joined  by  his  profes- 
sional adviser,  the  person  being  young,  and  of  more  than  commonly 


556  ORAL  DISEASES  AND  SURGERY. 

vigorous  habits.  The  primary  lesion  here  was,  without  doubt,  the 
dead  lateral  incisor.  Why  this  should  have  provoked  such  exten- 
sive disease  I  am  at  a  loss  to  say.  In  this  particular  instance,  as 
in  many  cases,  the  disease  was  developed  and  advanced  without 
any  very  marked  acute  manifestations,  a  not  uncommon  feature  in 
caries,  and  one  which  is  of  much  importance  to  be  borne  in  mind. 
A  whole  jaw  may  be  softened  and  destroyed,  while  the  patient  rests 
under  the  false  impression  that  he  has  no  trouble  that  is  beyond 
cure  through  the  loss  of  a  tooth.  I  have  occasionally  met  with 
cases  of  this  kind,  where  the  adviser  and  the  advised  have  been  alike 
deceived. 

The  slowness  or  the  rapidity  with  which  caries  of  the  jaw  pro- 
gresses is  influenced  by  individual  conditions.  Thus,  in  the  periods 
of  dentition,  the  disease  will  commonly  be  found  to  make  rapid  pro- 
gress, unless,  indeed,  the  vital  forces  are  very  resistive;  while  in 
the  mercurially  weakened  bone,  caries  seems  sometimes  analogous 
to  a  simple  mechanical  disintegration,  as  if,  indeed,  the  particles  of 
bone  had  lost  the  power  of  cohesion. 

The  peculiar  affinity  existing  between  this  disease  and  the  cellular 
tissue  of  the  bones  leads  to  the  inference  that  it  is  more  common  to 
persons  whose  skeletons  are  loose  and  spongy  in  character  than  to 
the  reverse  class ;  and  this  is  markedly  true:  hence  strumous  chil- 
dren are  very  subject  to  caries,  as  is  so  often  witnessed  in  their 
articular  complaints. 

In  many  subjects  the  condition  seems  to  be  that  of  a  semi-fatty 
degeneration,  the  animal  portion  of  the  bone  becoming  quite  soft 
and  greasy ;  indeed,  even  the  osseous  particles  thrown  off  present 
the  same  aspect.  The  relationship  of  the  disease  with  tubercular 
deposits  is  so  fully  established  in  the  minds  of  many  that  they 
incline  to  the  conviction  that  such  tubercle  is  present  at  all  points 
of  the  manifestation  of  caries.  That  this  is  not  fully  true,  is  i)roven 
by  examples  such  as  have  been  alluded  to.  Thut  constitutional 
causes  have,  however,  quite  as  much  to  do  with  the  development 
of  caries  as  have  local  injuries,  is  made  sufficiently  evident  in  the 
immunity  of  the  numberless  persons  who  have  been  brought,  with- 
out ill  result,  under  the  influences  of  similar  local  sources  of 
irritation. 

It  has  been  suggested  that  caries  may  exhibit  itself  in  various 
ways.  Yet,  however  and  whatever  the  manifestation,  an  ostitis — 
chronic  or  acute — must  precede  the  ulceration.  About  the  jaws  the 
great  majority  of  cases  have,  in  their  incipiency,  nothing  to  distin- 


CARIES   OF  THE  MAXILLA.  557 

guish  them  from  ordinary  periodontitis ;  and  it  is  by  far  most 
frequently  the  ease  that  the  acute  attack  has  been  long  past  before 
this  peculiar  ulceration  is  developed,  it  seeming  to  be  that  the  resist- 
ive power  of  the  bone  is  gradually  worn  out  by  the  presence  of 
chronicity;  the  inflamed  tooth  has  died,  and  its  devitalization  is  the 
source  of  offense.  Nearly  every  case  of  caries  of  the  jaws  that  I 
have  seen  could  have  been  aborted  by  the  timely  removal  of  a  certain 
tooth  or  teeth, — not,  of  course,  all,  but  that  great  majority  which 
have  had  dental  irritation  as  the  exciting  cause. 

A  carious  bone  presents  clinical  peculiarities  according  to  the 
duration  of  the  disease  and  the  several  phases  of  the  causes  inducing 
it.  If  seen  early,  there  is  to  be  observed  simply  the  increased 
vascularity  and  congestion  of  the  inflammation.  A  little  later,  and 
a  cacoplastic  exudate  occupies  the  cells,  which  cells,  in  their  turn, 
have  become  enlarged,  and  their  w^alls  decalcified  ;  these,  still  later, 
comiaience  gradually  to  break  down,  together  with  the  semi-organized 
lymph  exuded  into  them  ;  in  proportion  as  such  exudation  has  been, 
and  is,  extensive,  and  the  breaking  down  is  rapid,  the  caries  may 
be  said  to  be  dry  or  moist  Such  exudation  and  degeneration  are 
markedly  exhibited  in  many  cases  of  hip  disease,  or  white  swelling 
of  the  knee-joint,  where  the  discharge  may  amount  to  quite  as  much 
as  a  pint  a  day.  Upon  now  looking  at  the  bone,  we  find  it  riddled  with 
irregular  cavities,  many  or  all  of  which  are  lined  by  a  sort  of  imper- 
fect secretory  surface,  or  perhaps  it  would  be  more  correct  to  say,  a 
glazing  of  semi-organized  exudate  corpuscles.*     If  the  disease  is  to 

*  "The  whole  essence  of  caries  consists  in  this:  the  hone  breaks  up  in  its 
territories,  the  individual  corpuscles  undergo  new  developmental  changes 
(granulation  and  suppuration),  and  remnants  composed  of  the  oldest  basis- 
suhstance  remain  in  the  form  of  small,  thin  shreds  in  the  midst  of  the  soft 
substance.  In  ossification  (in  cartilage)  there  is  a  portion  of  the  original 
intercellular  substance  of  the  cartilage-cells  (secondary  cells)  which,  though 
it  belongs  to  the  group  as  a  whole,  yet  when  these,  in  the  course  of  ossifica- 
tion, are  transformed  into  a  number  of  isolated  bone-cells,  becomes,  compara- 
tively speaking,  almost  entirely  independent  of  those  cells  individually  (which 
have  their  own  immediate  intercellular  substance  to  attend  to,  and  from  most 
of  which  it  must  be  separated  by  a  considerable  interval),  and  therefore 
escapes  the  changes  which  befall  them.  It  is  this  portion  which  remains 
behind  in  caries,  while  the  secondary  intercellular  substance  perishes.  In 
other  processes,  however,  which  run  a  more  chronic  course  (in  cancer,  for 
example),  everything  is  destroyed. 

"  At  the  moment  a  periosteal  tissue  quits  the  surface  of  a  bone,  and  the  vessels 
are  drawn  out  from  the  cortex  in  inflammatory  condition,  wo  see,  not  as  in  normal 


558  ORAL  DISEASES  AND   SURGERY. 

involve  the  whole  bone,  such  will  be  its  general  condition.  If,  how- 
ever, there  reside  in  the  part  the  vital  force  capable  of  resisting  the 
disease,  then  from  the  central  point  of  the  disease  outward  will  be 
observed  a  change  in  the  character  of  the  lymph  exuded.  The 
farther  we  get  from  the  centre,  the  more  bland  and  healthy  is  the 
exudate  ;  while  the  complete  filling  up  of  the  cells  (structural  con- 
solidation) exhibits  the  wall  of  protection  present  in  circumscribed 
healthy  inflammation  of  the  soft  parts.  It  is  to  be  observed,  how- 
ever, that  this  protecting  wall  is  most  apt  to  give  way  before  the 
advance  of  the  disease, — seeming  to  retard  but  not  to  check  it.  In 
other  words,  nature  seems  seldom  able,  unassisted,  to  complete  a 
line  of  demarkation,  as  witnessed  in  necrosis. 

bone,  mere  threads,  but  little  plugs,  thicker  masse-s  of  substance;  and  if  the\'have 
been  entirely  drawn  out,  there  remains  a  disproportionately  large  hole,  much 
more  extensive  than  it  would  be  under  normal  circumstances.  On  examin- 
ing one  of  these  plugs,  j'ou  will  find  that  around  the  vessel  a  certain  quantity 
of  soft  ti.ssue  lies,  the  cellular  elements  of  which  are  in  a  state  of  fatty  degen- 
eration. At  the  spot  where  the  vessel  has  been  drawn  out  the  surface  does 
not  ajipear  even,  as  in  normal  bone,  but  rough  and  porous,  and  when  placed 
under  the  microscope,  you  remark  those  excavations,  those  peculiar  holes, 
which  correspond  to  the  liquefying  bone-territories.  If  it  be  asked,  therefore, 
in  what  way  bone  becomes  porous  in  the  early  stage  of  caries,  it  may  be  said 
that  the  porosity  is  certainlj'  not  due  to  the  formation  of  exudations,  seeing 
that  for  these  there  is  no  room,  inasmuch  as  the  vessels  within  the  medullary 
canals  are  in  immediate  contact  with  the  osseous  tissue.  On  the  contrary,  the 
substance  of  the  bone  in  the  cellular  territories  liquefies,  vacuities  form,  which 
are  fir.-^t  filled  with  a  soft  substance,  composed  of  a  slightly  streaky  connective 
tissue  with  fattily  degenerated  cells.  If  round  about  a  medullary  canal  the 
territory  of  one  bone-corpuscle  after  another  liquefies,  you  will,  after  a  time, 
find  the  canal  bounded  on  all  sides  by  a  lacunar  structure.  In  the  middle  of 
it,  the  vessel  conveying  the  blood  still  remain.s,  but  the  subistance  around 
about  it  is  not  bone  or  exudation,  but  degenerate  tissue.  The  whole  process 
is  a  degenerative  ostitis,  in  which  the  os.seous  tissue  changes  its  structure, 
loses  its  chemical  and  morphological  characters,  and  so  becomes  a  soft  tis.«ue 
which  no  longer  contains  lime.  The  tissue  which  fills  the  resulting  vacuity 
in  the  bone  may  vary  extremely  according  to  circum.stances,  consisting  in 
one  case  of  a  fattily  degenerating  and  disintegrating  substance  (the  bone-cor- 
puscles perishing),  and  in  another  of  a  substance  rich  in  cells,  and  containing 
numerous  young  cells  ;  this  latter  is  formed  by  the  division  and  proliferation 
of  the  bone-corpuscles,  and  the  newly-produced  substance  is  very  analogous 
to  marrow.  Under  certain  circumstances  this  substance  may  grow  to  such 
an  extent  that — if  we  may  again  borrow  our  illustration  from  the  surface  of 
the  bone  where  a  vessel  sinks  in — the  young  medullary  matter  sprouts  out 
by  the  side  of  the  vessel,  and  appears  as  a  little  knob  filling  one  of  the  pits  in 
the  surface.     This  we  call  granulation." — ViRCHOW. 


CARIES   OF  THE  MAXILLA.  559 

Treatment. — To  do  all  that  can  be  done  in  these  cases  is  not  at 
all  difficult.  If  inflammation  of  the  bone  exists  in  an  acute  stage, 
it  is  to  be  treated  on  general  principles :  cathartics,  diaphoretics, 
counter-irritants,  hot  pediluvia,  leeches,  the  general  abstraction  of 
blood,  any  or  all  of  these  means  being  brought  into  requisition,  the 
practitioner  being  influenced  alone  by  the  resistance  of  his  case.  If 
a  tooth  inflamed  in  its  enveloping  membrane  be  the  cause  of  the  in- 
flammation, as  is  most  frequently  the  case,  such  tooth  is  to  be  removed, 
or  it  may  be  treated.  Generally,  in  such  an  inflammation,  it  will  be 
found  sufficient  to  scarify  the  gums,  give  a  hot  foot-bath,  apply  a 
blister  to  the  back  of  the  neck,  and  administer  a  saline  cathartic.  If 
such  a  course  should  not  abort  or  conquer  the  trouble,  then  three  or 
four  Swedish  leeches  may  be  applied  directly  to  the  inflamed  part, 
this  being  easily  accomplished  by  introducing  a  napkin  back  of  the 
middle  of  the  roof  of  the  mouth.  If  even  this  should  not  succeed, 
and  the  patient  is  plethoric,  blood  may  be  taken  from  the  arm. 

It  is,  however,  frequently  the  case  that  even  what  may  be  viewed 
as  the  acute  stage  will  be  found  of  an  asthenic  type.  In  these 
cases,  conjoined  with  the  local  depletion,  tonics  will  be  demanded : 
iron,  quinia,  beef-essence,  cod-liver  oil,  etc.  being  indicated.  If, 
when  a  case  is  first  seen,  the  caries  has  become  established,  the 
acute  action  having  resolved,  as  recognized  by  the  existence  of 
fistulas,  the  honeycomb-bone,  etc.,  vigorous  tonic  medication,  con- 
joined with  stimulating  injections,  maybe  tried.  Of  such  injections, 
the  tincture  of  iodine,  carbolic  acid,  compound  tincture  of  capsicum, 
and  chloride  of  zinc,  will  be  found  as  promising  as  any.  Of  the 
tonics,  I  presume  a  common  experience  will  give  to  the  chalybeates 
a  pi-eference.  It  is  not,  however,  from  the  medication  alone 
that  a  cure  is  commonly  to  be  expected.  In  caries  nature  seeiiis 
unable  to  throw  off  the  incubus  of  the  disease ;  and  the  cases  are 
rare  indeed  where  relief  by  operative  means  will  not , be  found, 
imperatively  demanded.  Such  operative  means,  however,  to  be  of 
profit  to  a  case,  must  be  well  considered.* 

*  "  Prevention  is  obviously  the  paramount  indication.  With  this  view,  if 
symptoms  of  interstitial  absorption  be  present,  our  attention  will  be  directed 
to  the  arrest  of  this  by  counter-irritation  and  constitutional  care.  If  a  simple 
abscess  or  ulcer  occurs  on  the  surface  of  bone,  it  will  be  our  object  to  effect 
the  healing  of  this  as  rapidly  as  possible,  in  order  to  prevent  degeneration. 
When  mere  ostitis  is  present  and  demands  our  aid,  we  shall  treat  it  actively 
yet  warily :  actively,  in  order  to  arrest  the  inflammatorj*  process  ere  yet  the 
untoward  results  of  suppuration  or  ulceration  have  occurred ;   warily,  avoid- 


560  ORAL  DISEASES  AND   SURGERY. 

To  operate  for  carles  of  the  jaws  one  seldom  requires  more  than 
two  or  three  delicatelj-curved  chisels,  a  scalpel,  syringe,  and  an 

ing  exhaustion  of  the  system,  and  still  more  the  poisoning  of  it  bj'  excess  of 
mercurial  and  other  active  antiphlogistics  ;  careful  not  to  induce  a  state 
favorable  to  the  occurrence  of  destruction  in  bone.  And  seeing  that  caries 
is  usualh^  so  much  connected  with  taint  of  system,  our  attention  will  be 
directed  throughout  toward  constitutional  care  in  connection  with  both  pre- 
vention and  cure. 

"When  caries  has  occurred,  the  indications  of  local  treatment  are  abun- 
dantly simple.  We  are  to  take  away  the  two  portions  which  are  incapable 
of  healthy  effect, — the  interstitiallj'  absorbed  as  well  as  the  truly  ulcerous; 
leaving  a  solid  foundation  of  normal  texture,  not  only  capable  of,  but  already 
engaged  in,  the  business  of  cflBcient  repair.  Afterward,  the  part  is  to  be 
treated  as  a  simple  ulcer  ;  our  anxious  care  being  directed  to  speedy  yet 
efficient  and  certain  closure,  lest  renewed  degeneration  supervene;  not  rest- 
ing satisfied  with  a  blue,  elevated,  soft,  and  spongy  cicatrix,  but  insisting  on 
the  establishment  of  one  which  is  firm,  Avhite,  depressed, — plainly  incorpo- 
rated with  the  bone. 

"For  effecting  the  removal,  cutting  instruments  are  infinitely  preferable  to 
escharotics,  in  all  situations  where  excision  is  practicable.  But  as  a  general 
rule,  no  operation  of  any  kind  should  be  performed  on  the  bone  unless  the 
adjacent  and  superimposed  soft  parts  are  in  a  quiet  state.  They  may  be 
undergoing  the  acute  inflammatory  process ;  they  may  be  the  seat  of  acute 
suppuration,  of  acute  ulceration,  or  of  both  ;  and  removal  of  a  portion  of 
bone,  imbedded  in  such  soft  parts,  is  almost  certain  not  only  to  prove  futile 
as  a  means  of  cure,  but  actually  to  aggravate  and  extend  disease.  The  then 
carious  portion  of  bone  may  be  taken  away,  but  ulceration  instead  of  repara- 
tion is  certain  to  ensue;  and  by  rapid  degeneration  the  carious  condition  is 
renewed;  or  a  more  general  and  intense  ostitis  is  kindled,  and  the  partial 
caries  is  merged  in  general  necrosis.  And  even  supposing  none  of  these 
untoward  events  to  occur,  still  the  time  of  operation  were  inexpedient,  as 
causing  an  unnecessary  and  therefore  unwarrantable  amount  of  secondary 
inflammation. 

"  The  soft  parts  being  already  quiet,  or  having  become  so  under  suitable 
treatment,'  free  incision  is  made  through  them,  so  as  effectually  to  expose  the 
diseased  portion  of  bone, — previously  tolerably  well  explored  by  judicious 
use  of  the  probe.  The  extent  of  the  doomed  parts  having  been  satisfactorily 
ascertained,  their  thorough  removal  is  then  to  be  accomplished. 

"  Escharotics  in  some  cases  are  employed  ;  as,  for  example,  when  a  patient 
resolutely  objects  to  any  other  mode  of  removal.  Or  when  cutting  instru- 
ments have  been  used,  and  yet  a  border  of  suspicious  character  remains,  the 
extinction  of  such  a  suspected  part  may  sometimes  be  conveniently  enough 
intrusted  to  cauterization.  The  actual  cautery  may  be  applied,  but  unwisely. 
It  effects  too  much.  The  carious  part  is  at  once  and  satisfactorily  killed  ;  but, 
as  in  all  severe  burns,  the  texture  immediately  surrounding  the  eschar, 
though  escaping  with  life,  has  its  vitality  very  much  impaired,  and  is  more 


1 


I 


CARIES   OF   THE  MAXILLA.  561 

acidulated  water.  Taking  the  fistula  for  the  guide,  the  bone  is  ex- 
posed by  a  simple  incision.  Xext,  with  a  chisel,  suitable  in  size, 
the  softened  structure  is,  little  by  little,  cut  away. 

The  extent  to  which  caries  will  occasionally  be  found  to  have 
progressed  is  a  matter  of  surprise.  One  can  do  no  better,  how- 
ever, than  follow  the  softened  bone,  wherever  it  may  lead.  I  have 
very  frequently,  in  this  way,  been  led  from  an  apparent  simple  be- 
ginning, to  remove  nearly  or  quite  all  of  the  upper  jaw.  Danger 
from  hemorrhage  has  not  been,  in  m^'  experience,  any  special  occa- 
sion of  anxiety;  indeed,  I  fail  to  recall  a  case  in  which  the  injection 
of  alum-water  has  not  been  all-sufficient  for  its  control.  When 
healthy  bone  is  reached  in  an  operation,  it  is  distinguished  from  the 
carious  both  by  the  touch  and  sight.  Under  the  gouge  the  first  is 
hard  and  springy,  the  latter  soft  and  brittle.  Passing,  with  the  in- 
strument, from  the  diseased  to  healthy  tissue,  one  could  not  fail  to 
remark  a  difference.  To  the  sight,  healthy  bone  is  white  and  vas- 
cular ;  carious  bone  is  dark  and  non-vascular,  or  it  is  a  deadish  white, 
or  oleaginous.  A  very  observable  difference  between  caries  and 
necrosis  consists  in  the  absence,  in  the  former,  of  the  odor  associ- 
ated with  the  latter,  caries  running  its  whole  course  without  neces- 
sarily giving  the  slightest  annoyance  from  this  cause  ;  at  least, 
where  proper  cleanliness  has  been  observed. 

The  use  of  the  syringe,  after  an  operation  for  caries,  is  of  the 
greatest  moment;  the  capacity  should  not  be  of  less  than  one  gill, 
and  every  particle  of  detritus  is  to  be  carefully  washed  away.  In  the 
after-treatment,  this  instrument  will  also  be  found  to  perform  good 
service, — repeated  washings  with  the  proper  medicaments  being 
very  conducive  to  a  cure. 

The  use  of  sulphuric  acid  in  the  treatment  of  caries,  designed  to 
unite  with  the  base  of  the  phosphatic  salts  of  the  bone,  and  thus 
remove  it,  introduced  into  practice  by  George  Pollock,  F.R.C.S., 
surgeon  to  St.  George's  Hospital,  has  justly  attracted  much  atten- 
tion. Used  in  that  state,  in  which  nature,  possessed  of  the  requisite 
resistive  force,  has  compelled  the  line  of  demarkation,  and  needs 
only  the  assistance  of  relief  from  the  dead  tissue,  sulphuric  acid 

prone  to  disintegration  than  to  repair.  The  potential  cautery  is  infinitely 
preferable.  It  destroys  the  diseased  part  just  as  effectually,  though,  perhaps, 
with  less  rapidity,  and  at  the  same  time  the  immediately  adjoining  parts  do 
not  in  any  wise  suffer,  but  at  once  institute  a  healthful  line  of  demarkation 
for  removal  of  the  dead  part,  and  are  well  able  to  commence,  at  the  same 
time,  a  sthenic  action  of  repair." — Miller. 

36 


562  ORAL  DISEASES  AND  SURGERY. 

employed  in  a  required  strength  will  undoubtedly  dissolve  such 
dead  bone  and  thus  allow  a  cure.  Again,  used  as  a  local  stimulant, 
it  exerts  most  excellent  influence,  exciting  into  action,  and  seeming 
to  afford  support  to  all  the  abeyant  force  of  the  parts.  Still  again, 
used  as  an  antiseptic,  its  effects  are  very  beneficial,  assisting  in  keep- 
ing the  parts  fresh  and  clean. 

In  using  sulphuric  acid  with  a  view  to  the  solution  of  dead 
bone,  one  part  of  the  officinal  may  be  diluted  with  eight  of  water  ; 
or,  if  preferred,  the  aromatic  acid  may  be  used  either  pure  or  diluted. 
Mr.  Pollock  himself  uses  the  acid,  at  first  diluted  with  ecpial  parts 
of  water,  and  then  more  and  more  nearly  pure,  penciling  the  surface 
which  he  exposes  by  turning  aside  the  soft  parts.  When  the  acid 
is  employed  simply  as  a  stimulant  or  antiseptic,  the  circumstances 
of  each  case  will  govern  the  strength  of  the  application. 

The  employment  of  caustic  potash  for  destroying  quickly  disin- 
tegrating bone  has  the  recommendation  of  no  less  eminent  authority 
than  Dr.  Fitzgerald,  of  Dublin.  When  tested,  however,  by  the  side  of 
sulphuric  acid,  it  is  to  be  agreed  that  there  is  no  comparison.  With 
the  former  agent,  secondary  injuries  may  associate  ;  with  the  latter, 
nothing  but  good  is  to  be  anticipated.* 

*  "Acid  does  not  affect  or  injure  the  soft  tissues  when  used  in  the  diluted 
form :  actins;  chemically  on  the  diseased  bone  alone,  it  does  not  affect  the 
living  bone,  and  its  application  is  seldom  followed  by  any  great  degree  of 
pain. 

"  That,  in  the  diluted  form,  it  will  only  act  on  dead  or  diseased  bone,  and 
not  on  healthy  bone,  is  a  point  of  very  considerable  practical  importance, 
and  is  the  great  advantage  sulphuric  acid  possesses  as  an  application,  under 
the  circumstances  quoted,  over  the  use  of  the  gouge,  or  of  the  actual  cautery, 
or  of  caustic  potash.  The  following  experiments,  conducted  at  my  request  by 
Mr.  Henry  M.  Noad,  lately  my  clinical  clerk,  satisfactorily  prove  the  cor- 
rectness of  this  statement. 

"  Portions  of  dead,  diseased,  and  healthy  bone  were  selected  and  subjected 
to  the  action  of  sulphuric  acid,  viz.  : 

"  1.  Dead  bone,  10  grains. 
"  2.  Diseased  bone,  10  grains. 
"  3.  Healthy  bone,  middle  age,  10  grains. 
"  4.  Healthy  bone,  old  age,  10  grains. 
Exposed  to  the  action  of  a  mixture  of  sulphuric  acid  and  water,  one  part  in 
four,  for  three  days,  at  a  temperature  of  100°,  the  following  were  the  results : 
"  1.  Dead  bone:    Phosphate  of  lime,  2  gr.  ;  carbonate  of  lime,  3.30  gr. ; 

dissolved  in  the  mixture. 
"  2.  Diseased  bone  :  Phosphate  of  lime,  2  gr. ;  carbonate  of  lime,  1.3  gr.  ; 
dissolved  in  the  mixture. 


CARIES  OF  THE  MAXILLA.  563 

Illustrations  in  Practice. — Mary  B ,  girl  of  weakly  constitu- 
tion, with  caries  of  inferior  maxilla  involving  the  body  of  the  bone 
from  the  second  bicuspis  of  one  side  to  the  first  molar  of  the  other, 
the  teeth  being  in  place,  but  very  loose,  three  sinuses  existing  in  the 
gum  overlying  the  disease,  which  sinuses  were  in  constant  discharge. 
Examination  with  a  sharp-pointed  steel  probe  exhibited  the  bone  as 
so  honeycomb-like  that  the  instrument  could  be  pushed  through  the 
parts  without  difficulty. 

Treatment  and  Result. — Patient  kept  on  a  chalybeate  tonic  for 
three  weeks,  then  operated  upon  before  hospital  class.  Desirous  of 
testing  the  reparative  powers,  a  cut,  uniting  several  sinuses,  was 
made  below  the  apices  of  the  roots  of  the  teeth,  and  with  delicate 
gouges  the  softened  bone  was  scraped  away,  allowing  the  teeth  to 
remain  supported  almost  exclusively  by  the  gum.  After  the  opera- 
tion, the  parts  suppurated  from  the  superficies  of  the  bone  more  or 
less  for  three  months,  the  left  cuspis  being  thrown  off  by  a  slough 
of  the  immediately  overlying  gum.  At  the  end  of  this  period,  an 
osteophytic  sequestrum  was  exfoliated,  after  which  the  wound 
closed,  the  teeth  gradually  became  firm,  and  a  cure,  with  the  teeth 
preserved,  was  happily  secured.  Locally,  sulphuric  acid  alternated 
with  the  chloride  of  zinc  was  used.  Systeraically,  advantage  was 
endeavored  to  be  taken  of  all  tonic  influences  :  exercise  in  the  open 
air,  and  sunshine,  salt-water  sheet-baths,  juicy  undercooked  meat, 
the  compound  tincture  of  gentian  as  an  appetizer,  etc. 

The  use  of  sulphuric  acid  in  caries,  acting  to  the  chemical  de- 
composition of  bone,  may  readily  be  conceived  as  possessed  of  much 
good  import ;  indeed,  it  may  very  well  be  recognized  as  possessed 
in  itself  of  power  sufficient  to  a  cure,  doing  chemically  that  which 
the  gouge  does  mechanically.  The  strength  in  which  an  acid  is  to 
be  used  depends  entirely  upon  the  effect  desired  to  be  accomplished. 

"  3  and  4.     In  both  specimens  of  healthy  bone,  no  action  took  place. 

"  The  process  of  disintegration  or  dissolution,  with  the  commencement  of 
healthy  granulation  from  the  surface  of  the  living  bone,  may  be  observed 
simultaneously  progressing,  in  any  exposed  surface  of  dead  or  dying  bone  to 
which  the  acid  may  have  been  applied.  When  its  action  and  eflfects  are  com- 
pared with  those  of  the  gouge,  the  brui.<ing  which  is  necessarily  produced  by 
the  use  of  the  latter,  the  pain  and  frequent  subsequent  inflammation,  and, 
even  under  the  most  favorable  circumstances,  the  time  required  for  the  rough 
lacerated  surface  to  recover  itself,  throw  otF  its  small  bruised  fragments,  and 
become  covered  with  granulations,  the  treatment  by  sulphuric  acid  will  be 
found  far  preferable." — Pollock. 


564  ORAL  DISEASES  AND  SURGERY. 

If  employed  with  the  anticipation  of  decomposing  the  affected  bone, 
the  undiluted  aromatic  sulphuric  will  scarcely  be  found  over-strong. 
Personally  I  have  frequently  made  test  of  such  strength,  and  even 
much  stronger,  using,  indeed,  the  pure  officinal  ordinary  sulphuric 
acid,  taking,  however,  the  precaution  to  make  direct  applications 
with  a  stick  brush.  Where  the  acid  is  used  merely  as  a  stimulant, 
the  aromatic  is  to  be  diluted  j^^o  re  nata. 

Case  II. — French  lady,  about  twenty-three  years  of  age ;  caries 
of  base  of  alveolus  of  right  cuspis  of  superior  jaw,  involving  the 
palatine  process,  with  discharge  beneath  the  covering  of  the  hai'd 
palate ;  two  tumors,  one  the  size  of  a  hickory-nut,  the  other  that  of 
a  hazel-nut,  existing. 

Treatment. — First  opened  the  sacs,  giving  vent  to  the  accumu- 
lated pus,  the  bone  being  found  denuded  quite  the  size  of  a  dime- 
piece.  Once  each  day,  for  the  period  of  two  weeks,  the  sacs  were 
injected  with  sulphuric  acid  and  water,  one  part  of  the  first  to  twelve 
of  the  second.  At  the  end  of  this  time  the  cure  was  complete, 
granulations  after  the  sixth  day  being  recognized  as  covering  the 
exposed  bone. 

In  this  second  case,  close  observation  elicited  the  fact  that  the 
acid  acted  just  as  any  other  stimulant  Avould  have  done.  Iodine 
or  zinc  might  have  been  used  with  a  precisely  similar  result,^ — power 
existing  in  the  natural  force  of  the  patient  to  overcome  the  destruc- 
tive condition,  requiring  only  the  aid  of  slight  stimulation. 

Case  III. — Merchant  from  Xew  York  City  ;  caries  of  both  palate- 
plates  of  superior  maxillae.  In  this  case,  while  two  sinuses  existed, 
the  mucous  envelope  of  the  hard  palate  was  found  separated  from 
its  bony  base,  forming  a  tumor  which  half  filled  up  the  mouth.  Ex- 
amination revealed  the  palatine  processes  riddled  with  holes.  This 
was  a  character  of  case  most  admirably  suited  to  acid  treatment, 
and  which  was  recommended.  A  diagnosis  of  different  character 
afterward  offered  in  another  city  resulted,  however,  in  resection  of 
the  bones  ;  an  operation  as  unnecessary  as  the  diagnosis  was  faulty, 
and  from  which  operation  the  author  is  under  the  impression  the 
patient  died. 

Case  IY. — A  very  delicate  lady,  about  twenty  years  of  age  ;. 
caries  arising  from  presence  of  a  lateral  incisor  tooth  containing  a 
dead  pulp.  When  this  patient  first  presented  herself,  no  external 
evidence  of  disease  existed,  except  that  implying  chronic  inflamma- 


CARIES  OF  THE  MAXILLA.  565 

tioa  of  the  membrane  surrounding  the  root  of  the  tooth,  the  organ 
being  loose,  slightly  elongated,  and  sore  ;  the  gum,  however,  over  the 
apex  of  the  root  was  healthy-looking.  Treatment  directed  to  the  cure 
was  commenced  by  drilling  an  opening  into  the  pulp  chamber,  through 
the  palatine  face  of  the  tooth  ;  the  cavity  entered,  a  discharge  of 
pus  was  the  result.  A  succeeding  step  was  an  exploration  of  the 
parts  about  the  apex  of  the  root,  effected  by  passing  a  sharp  steel 
probe  through  the  soft  parts.  This,  meeting  bone,  was  thrust  for- 
ward, revealing  a  cavity  the  size  of  a  hazel-nut,  the  parietes  of  which 
were  found  spongy  and  soft.  This  cause,  condition,  and  character  of 
caries  are  those  most  frequently  met  with  in  the  upper  jaw.  Treat- 
ment of  the  case,  which  resulted  in  a  cure  in  ten  days,  was  as 
follows  : 

The  pulp  chamber  was  thoroughly  washed  out  with  water  medi- 
cated with  creasote.  The  length  and  circumference  of  the  pulp 
canal  were  measured,  and  a  delicate  pyramidal  cylinder  of  gold 
was  passed  and  consolidated  to  the  apex.  This  manipulation  was 
not,  however,  a  necessity,  but  had  reference  to  the  preservation  of 
the  future  usefulness  and  color  of  the  tooth.  This  accomplished, 
the  parietes  of  the  carious  cyst  were  well  broken  up  by  means  of  a 
sharp  excavator,  and  the  detritus  removed  through  the  aid  of  the 
syringe.  Injections  of  sulphuric  acid  and  water,  one  part  of  the  first  to 
eight  of  the  second,  were  now  used  for  ten  successive  mornings, 
w^hen  the  cyst  was  found  filled  with  organizable  material,  and  the 
cure  remained  complete. 


CHAPTER    XXYIII. 


NECROSIS. 


Directing  attention  to  the  foot-notes,  as  embracing  a  diversi- 
fied discussion  of  the  condition  and  character  of  necrosis,  the  text 
of  the  chapter  will  present  the  subject  in  its  clinical  aspect.* 

Necrosis,  signifying  death  of  bone,  while  common  to  b>)th  the  supe- 
rior and  the  inferior  maxilla,  exhibits  decided  preference  for  the 
latter,  attacking  it,  as  the  author  would  be  led  to  infer  from  the  ex- 
perience of  his  own  practice,  in  twenty  cases  to  five  of  the  former. 
The  disease  presents  a  twofold  primary  expression.  It  may  com- 
mence as  a  general  ostitis :  stasis  of  the  circulation  quickly  antag- 

*  "As  soon  as  that  peculiar  mutual  dependence  and  reciprocation  of  parts 
has  ceased  in  the  human  bodj',  which  emanates  from  their  genetic  unity,  and 
which  we  call  life,  it  encounters  the  same  conditions  of  the  outer  world  as  do 
the  inorganic  bodies  :  that  is  to  say,  the  only  force  which  tends  to  maintain 
it  in  its  form  is  cohesion.  This,  however,  owing  to  the  extraordinary  abun- 
dance of  water,  is  very  limited,  and  hence  immediately  after  the  occurrence 
of  death  the  decay  of  the  body  begins,  which  takes  place  at  first  slowly,  then, 
however,  continually  more  and  more  rapidly,  and  finally  leads  to  its  complete 
dissolution.  As  long,  moreover,  as  the  outer  form  is  in  any  measure  retained, 
we  call  the  body  dead,  understanding  by  this  term  that  a  body,  although  still 
exhibiting  organic  structure,  is  no  longer  the  seat  of  organic  function. 

"At  the  death  of  the  entire  organism,  medical  skill,  as  it  is  known, ceases. 
We  might,  therefore,  spare  ourselves  the  trouble  of  studying  the  changes 
which  the  death  of  the  tissues  occasions,  were  there  not  also  a  partial  death, 
or  death  of  individual  parts  of  the  organism,  which  we  call  necrosis,  morti- 
fication, gangrene. 

"The  anatomical  changes  which  follow  the  occurrence  of  partial  death  are 
not  the  same  in  every  case.  The  very  various  causes  producing  necrosis,  as 
well  as  the  natural  situation  and  constitution  of  the  dead  parts,  condition 
widely-separated  varieties,  especially  as  to  the  amount  of  blood  and  water 
contained,  which  give  occasion  to  the  production  of  a  dry  or  a  moist  gan- 
grene." 

For  a  series  of  the  most  widely-suggestive  and  practical  annotations  bear- 
ing upon  the  general  subject  of  necrosis,  the  reader  is  directed  to  Professor 
Kindfleisch's  Text-Book  of  Pathological  Histology,  pages  21  to  70. 
(f)66) 


NECROSIS.  567 

onizing  nutrition,  thus  killing  the  bone  outright ;  or,  as  more  com- 
monly witnessed,  it  is  a  result  of  periosteal  disease,  the  membrane 
affected  being  the  periosteum  proper,  or,  as  recognized  in  a  great 
majority  of  instances  in  which  the  condition  is  met  with,  the  alveole- 
dental  tissue, — periodonteum.  In  such  primary  membraneous  as- 
sociations, either  the  tissue,  as  it  reacts  upon  the  bone  life,  is 
found  dead,  or  it  is  seen  separated  from  the  bone  by  a  degener- 
ating plastic  exudate.*  In  such  inflammations  and  separations, 
it  would  be  inferred  that  the  layer  of  bone  immediately  adjacent 
to  the  membrane  would  be  the  first  to  be  affected  ;  this  is  so  truly 
the  case  that  timely  incisions  and  combating  of  the  inflammation  are 
most  influential  in  the  limitation  of  the  disease, — this  being  most 
markedly  exhibited  in  periodonteal  inflammation.  The  superior 
jaw,  however,  is  much  more  liable  to  take  on  a  general  inflammation 
than  the  inferior;  but  the  higher  vascularity  and  resistive  force  of 
this  part  seem  to  enable  it  to  resist  the  destructive  action  and  to 
limit  the  part  overwhelmed. 

Inflammation  of  the  jaws,  whether  osteal  or  periosteal,  is  pri- 
marily to  be  treated  on  general  principles.  If  acute  in  character,  we 
may  first  try  the  effect  of  the  hot  pediluvia  and  saline  cathartics. 
These  failing,  the  parts  may  be  well  scarified,  or  leeches  may  be 
applied,  or  blood  taken  from  the  arm.  Diaphoresis  may  be  employed. 
In  short,  antiphlogistics  of  any  and  every  nature,  promising  con- 
trol of  the  excitement,  may  be  pressed  into  service.  If  all,  however, 
fail,  and  pus  forms,  vent  cannot  too  soon  be  given  it.  When,  on  the 
contrary,  an  inflammation  is  chronic  and  asthenic  in  character,  as 
marked  in  the  puffy,  debased  character  of  the  parts  exhibited  in  the 
dyscrasic,  with  the  necessity  for  free  scarification  will  exist  a  demand 
for  local  stimulating  douches  and  the  administration  of  tonics.  Of 
the  supporting  medicines  applicable  to  these  cases,  the  very  best, 
I  think,  will  be  found  in  the  union  of  sulphate  of  quinia  with  the 
muriated  tincture  of  iron.  A  combination  very  frequently  employed 
is  as  follows : 

R. — Tincturte  ferri  chloridi,  3} ; 
Quinise  sulphatis,  5j-     M. 
Sig. — 15  drops  in  water  four  times  a  day  for  an  adult. 


*  In  necrosis  confined  to  part  of  a  bone,  the  increase  in  the  vascuhirity  of 
the  parts,  as  shown  by  the  curious  cases  exhibited  by  Mr.  Paget, — see  his  lec- 
tures on  Nutrition, — may  give  rise,  especially  in  young  persons,  to  hyper- 
trophy of  the  remainder. 


568  ORAL  DISEASES  AND   SURGERY. 

Ostitis,  as  a  primary  expression,  exhibits  its  most  intractable  cases 
in  the  periods  connected  with  dentition,  whether  first  or  second;  the 
irritability  being  increased  and  kept  up  by  the  excitability  associated 
with  this  psocess.  Hence  the  great  amount  of  care  necessary  to 
guard  against  any  increase  in  the  A'ascularity  natural  to  such  age. 
The  trouble  aroused,  nothing  can  be  done,  however,  beyond  such 
treatment  as  applies  to  ordinary  cases ;  except,  indeed,  it  will  be 
found  that  there  exists  a  greater  necessity  for  the  use  of  sedative 
medicaments. 

In  directing  treatment  to  a  condition  of  ostitis  or  periostitis,  as 
relation  is  had  with  necrosis,  an  indication  of  principal  signification 
lies  in  the  discovery^  and  removal  when  possible,  of  the  exciting 
cause  or  causes.  That  such  causes  may  have  proper  and  definite 
signification,  we  proceed  to  the  division  and  study  of  the  subject  as 
clinically  it  presents  its  diversified  phases  and  aspects. 

In  the  order  of  frequency  in  which  maxillary  necrosis  is  met  with, 
the  following  table  may  be  accepted  and  studied  : 

1.  Dental  necrosis. 

2.  Alveolar  necrosis. 

3.  From  lack  of  room  for  eruption  of  wisdom-tooth. 

4.  Syphilitic  necrosis. 

5.  Mercurial  necrosis. 

6.  Necrosis  from  injuries.* 

7.  Exantheniatous  necrosis. 

8.  Phosphor-necrosis. 


*  "  The  complete  cessation  of  nutrition  within  a  certain  mostlj'^  circum- 
scrihod  portion  of  bone  is  followed  hy  a  series  of  inflammatory  processes  in 
the  neighborhood,  whose  final  result  is  the  loosening  and  separation  of  the 
dead  from  the  living  parts.  The  course  of  these  changes  is  mostly  determined 
by  the  particular  cause  of  the  necrosis.  In  traumatic  necrosis,  under  certain 
circumstances,  the  loosening  of  the  dead  portion  from  the  living  is  already 
eflfected  (comminuted  fracture),  but  the  concealed  situation  makes  a  rapid 
extrusion  impossible  for  the  time  being.  In  injuries,  also,  a  purulent  peri- 
ostitis is  mostly  tlie  force  bringing  about  the  necrosis,  as  it  is  present,  as  the 
first  and  only  cause,  in  by  far  the  most  cases  of  necrosis.  The  purulent  peri- 
ostitis culminates,  as  has  been  mentioned,  in  a  collection  of  pus  between  the 
periosteum  and  bone.  A  preformed  cavity,  capable  of  dilatation,  does  not 
exist  here,  but  probably  the  cambian  layer  of  bone  (M.  Schultze),  especially 
in  youthful,  still-growing  bones,  is  so  soft  that  comparatively  slight  resistance 
is  ottered  to  its  loosening.  Only  the  vessels  which  pass  tolerably  numerous 
from  the  periosteum  to  the  cortex  of  the  bone,  must  be  ruptured,  and   it 


NECROSIS.  569 

Dental  IsTecrosis. — Dental  necrosis — death  of  the  teeth — may 
claim  a  first  attention  as  being  the  most  common  of  all  the  troubles 
of  the  ossa  corporis. 

depends  on  the  intensity  of  the  inflammation — that  is,  on  the  quantity  of  the 
pus — to  what  extent  this  is  accomplished.  This  laceration  of  the  vessels  is  not 
incorrectly  looked  upon  as  a  principal  cause  of  the  frequency  of  peripheral 
necrosis  after  purulent  periostitis.  It  is,  in  fact,  very  obvious  to  designate 
the  direct  interruption  of  the  supply  of  blood  to  the  outer  third  of  the  com- 
pact substance,  which  properly  belongs  to  the  periosteum,  as  the  cause  of  the 
complete  cessation  of  vital  processes  in  just  this  third.  Nevertheless,  although 
necrosis  does  not  follow  upon  purulent  periostitis  by  any  means  in  all  cases,  this 
must  not  determine  us  to  reject,  without  more  ado,  this  so  evident  etiological 
agent,  but  invite  us  to  seek  the  causes  of  the  exception  in  peculiar  relations  ; 
for  example,  in  a  substitution,  still  possible,  at  the  right  time,  of  the  cortical 
circulation  of  the  vessels  of  the  medulla.  Only  the  pus  itself  is  to  be  regarded 
from  the  beginning  as  something  excreted  from  the  organic  unity,  in  this 
sense  dead.  Its  presence  excites  a  sequestering  inflammation,  as  well  in  the 
periosteum  as  in  the  bone.  The  periosteum  is  very  soon  converted  into  a 
pyogenic  membrane,  which  protects  and  excludes  the  organism  against  its 
own  secretory  products.  In  the  bone  there  develops  a  rarefying  ostitis,  whose 
office  it  is  to  exclude  the  organisms  from  this  side  also  by  a  layer  of  granulation 
tissue  from  the  dead  part.  This  rarefying  ostitis  is  nourished  from  the  medulla, 
and  reaches  as  far  into  the  compact  substance  as  its  vascular  tracks  have  re- 
mained open  and  in  circulation.  There  are  cases  where  it  develops  upon  the 
upper  surface,  when  the  Haversian  canals  dilate  and  the  tissue  of  granulation 
springs  up  in  numberless  vascular  villosities  and  unites  into  a  continuous  layer, 
which  then  connects  with  the  elevated  periosteum  into  an  abscess  membrane 
inclosed  all  around.  More  frequently,  it  is  true,  the  outer  layers  of  the  com- 
pact substance  have  been  too  long  deprived  of  circulation  and  the  exchange 
of  material  for  their  revitalization  to  be  possible  by  the  medulla,  and  their 
own  rarefying  ostitis  appears  as  a  sequestering  inflammation,  which  separates 
the  lamellae  that  have  perished,  and  ends  in  pus,  which  fills  the  abscess  cavity. 
The  dead  bone  is  called  sequestrum  ;  the  rarefying  ostitis  which  sepai-ates  it, 
demarkation.  The  demarkation  may  occupy  months  and  years.  During  this 
time  the  suppuration  continues  uninterruptedly  ;  the  elevated  periosteum, 
however,  again  returns  to  its  ossifying  capacity,  and  forms  under  the  pyogenic 
surface  a  layer  of  new  osseous  tissue,  which  in  time  may  attain  a  very  con- 
siderable thickness.  A  bony  capsule,  called  coffin  (Todtenlade),  which  is  thus 
produced,  lodges  the  more  or  less  loosened  sequestrum  in  its  interior.  The 
adjacent,  not  elevated,  periosteum,  also  participates  by  ossifying  periostitis. 
For  a  distance  upward  and  downward  osteophytes  and  exostosis  arise  in  vary- 
ing form  and  number.  All  these  phenomena  of  inflammation,  extending  to 
some  distance,  disappear  as  soon  as  the  sequestrum  is  successfully  removed. 
Even  the  bony  capsule  diminishes,  and  by  the  obliteration  of  the  cavity  of 
the  abscess  it  again  applies  to  the  surface  of  the  bone,  the  exostosis  disappears, 
and  the  bone  again  assumes  its  normal  form." — Rixdfleisch. 


570  ORAL  DISEASES  AND   SURGERY. 

A  tooth  has  a  twofold  source  of  vitality, — an  internal  or  tubular 
circulation,  secured  from  its  pulp;   and  an  external  or  membranous. . 
The  destruction  of  this  internal  circulation,  through  the  killing  of 
the  pulp  and  filling  the  root-canal  with   metal,  is  so  common  an 
occurrence  as  to  be  familiar  to  almost  every  one. 

By  the  majority  of  teeth,  if  properly  treated,  such  destruction 
seems  to  be  sustained  without  much  apparent  inconvenience.  This 
treatment  consists,  as  we  have  learned,  in  extracting  from  the  cavity 
every  particle  of  the  dead  pulp,  and  so  filling  the  chamber  with  gold 
or  other  material  as  to  prevent  the  introduction  of  more  irritating 
matter.  Where  teeth,  however,  are  not  properly  treated,  or  where 
there  is  great  susceptibility  in  the  system  to  inflammatory  action, 
the  destruction  of  the  pulp  results  in  an  extension  of  the  destructive 
action  to  the  periodonteal  membrane,  yielding  the  trouble  known 
as  periodontitis;  this,  if  not  aborted  or  resolved,  terminates  in  the 
death  of  the  tooth. 

A  dead  tooth  is  not,  however,  fortunately,  treated  in  all  cases  by 
the  system,  or  even  in  the  majority  of  cases,  in  so  summary  a  man- 
ner as  a  piece  of  dead  bone.  As  a  rule,  there  exists  a  wonderful 
forbearance  on  the  part  of  nature  to  its  presence,  and  the  organ 
may  be  retained  in  its  cavity  and  made  to  serve  useful  purpose  for 
a  long  time.  True,  it  is  discolored,  and,  provided  there  is  no 
decomposing  pulp  in  the  canal,  in  proportion  to  this  discoloration 
may  the  degree  of  death — if  I  may  so  speak — be  judged.  A  tooth 
lowers  in  the  scale  of  vitality  in  various  degrees.  It  may  be  dete- 
riorated as  the  death  of  part  of  its  pulp  is  concerned,  or  as  the  death 
of  all  of  it  is  implied, — as  regards  the  whole  or  any  part  of  its  en- 
veloping membrane.  When  both  pulp  and  membrane  are  dead,  the 
tooth,  of  necessity,  must  be  dead  with  them  ;  and  in  proportion  to 
their  destruction,  so  is  its  destruction. 

Some  systems  are  so  irritable  that  all  skill  might  not  make  the 
mouth  retain  a  tooth  in  which  simph^  the  pulp  is  dead.  Others,  on 
the  contrary,  are  so  unimpressible  that  half  the  teeth  in  the  arch 
might  be  utterly  necrosed,  and  yet  no  complaint  be  made.  The  author 
once,  as  an  experiment,  replaced  in  the  mouth  a  central  incisor  tooth 
which  had  been  extracted  twelve  hours  before,  and  although  it  had 
been  carried  in  the  pocket,  enveloped  in  the  usual  collection  of  dust, 
tobacco,  keys,  knife,  etc.,  the  whole  intervening  time,  it  was  kept  in 
its  socket  until  the  parts  became  reconciled.  Many  years  have  since 
passed,  and  it  seemed,  when  last  seen,  about  as  useful  as  in  its 
palmiest  days.     The  repetition  of  this  experiment  is  now  common. 


NECROSIS.  671 

The  irritation,  inflammation,  and  death  of  a  tooth  are  generally 
the  result  of  caries  exposing  its  pulp.  The  first  stage  in  the  destruc- 
tive process  is  the  death  of  this  part  ;*  here  it  may  end,  the  pulp 
sloughing  off  at  the  foramen,  and  the  periodonteum  assuming  the 
full  duties  of  nutrition.  If  this  is  not  the  case,  this  membrane  be- 
comes involved;  if  it  too  should  die,  the  root  is  left  as  if  scraped  : 
the  tooth  is  then  dead.  A  dead  or  partly  dead  tooth  is  recognized 
by  its  loss  of  translucency,  the  opacity  varying  from  the  slightest 
discoloration  to  complete  blackness. 

A  dead  tooth  is  not,  however,  necessarily  associated  wnth  caries. 
Inflammation,  resulting  in  its  destruction,  may  be  induced  by  at- 
mospheric changes,  blows,  etc.  This  should  be  recognized,  so  that 
by  reason  of  the  absence  of  decay  a  diagnosis  may  not  be  obscured. 

A  dead  tooth  is  thrown  off  in  two  ways :  either  by  chronic  or 
acute  action.  When  by  acute  means,  violent  inflammation  is 
set  up  in  all  the  surrounding  parts,  the  tooth  is  elongated  and 
loosened,  much  pus  is  discharged,  and  eventually  the  tooth  drops 
from  its  socket ;  this  accomplished,  the  trouble  commonly  subsides. 
In  chronic  exfoliation,  the  parts  indurate,  one  or  more  sinuses  form 
as  in  ordinary  abscess,  all  the  parts  about  the  tooth  are  thickened 
and  rough,  as  if  some  ugly  disease  was  in  process  of  development, 
and  the  tooth  generally  grows  dark,  perhaps  black.  It  does  not  get 
loose,  but  is  apt  to  frighten  into  its  removal.  If  such  extraction  be 
not  resorted  to,  the  disease  involves  the  bone,  and  tooth  and  alveolus 
become  eventually  cast  off  as  a  common  sequestrum.  Another,  and 
more  common  chronic  form,  consists  in  the  gradual  absorption  from 
about  the  roots  of  a  dead  tooth  of  its  alveolar  process.  This  is 
most  common  to  old  persons,  although  not  by  any  means  so  con- 
fined. This  form  of  exfoliation  is  usually  very  slow  in  its  progress, 
extending  over  a  period  sometimes  of  several  years.  Cases,  how- 
ever, frequently  present — confined  to  young  persons — where  several 
teeth  are  cast  off  in  this  manner  within  eight  or  nine  months. 

Teeth  sometimes  die  as  the  result  of  general  structural  consolida- 
tion. This  never  occurs  but  in  what  are  commonly  recognized  as 
very  dense  teeth,  and  is  seldom  found  associated  with  caries.  Such 
teeth  loosen  day  by  day,  and  finally-^it  may  be  after  a  period  of 
years — drop  from  their  cavities.  The  condition  is  seen  alone  in  old 
persons,  or  in  those   beyond  middle  age.     To  arrest  this  trouble 

*The  pulp  of  a  tooth  is  composed  of  most  delicate  connective  tissue,  in 
which  ramify  the  vessels  and  nerve.  (See  diagram.) 


572  ORAL  DISEASES  AND  SURGERY. 

seems  impossible.  I  know  of  no  treatment  that  has  ever  seemed  to 
have  the  least  effect. 

Alveolar  Necrosis. — The  membrane  enveloping  the  root  of  a 
tooth  is  associated,  as  a  nutritional  vehicle,  with  its  alveolus  ;  hence 
it  is  commonly  termed  the  "  alveolo-dental  periosteum."  As  the 
result  of  such  relationship  of  structure,  an  inflammation  originating 
in  a  tooth  extends  to  the  surrounding  bone,  and,  according  to  its 
severity,  affects  the  parts  involved ;  hence  portions  of  alveolus, 
overwhelmed,  as  it  were,  by  the  force  of  the  attack,  sometimes  die 
and  sequester.  This  form  of  necrosis,  while  very  common,  would 
perhaps  with  proper  treatment  seldom  occur. 

The  dentist,  for  the  purpose  of  destroying  the  pulps  of  teeth, 
applies  the  arsenical  mixture.  This  is  placed  in  a  cavity  of  decay, 
and  covered  with  cotton  or  wax.  It  happens,  however,  occasion- 
ally, that  from  an  improper  application,  or  some  difficulty  of  retain- 
ing it  in  place,  the  paste  oozes  down  around  the  neck  of  the  tooth, 
and  thus  acts  upon  parts  not  intended  in  its  application,  inflaming 
them.  In  this  way  alveolar  necrosis  is  sometimes  induced  ;  the 
portion  destroyed  is  seldom,  however,  very  considerable,  and  gen- 
erally exfoliates  in  from  two  to  four  weeks.  The  local  application 
of  the  sesquioxide  of  iron  has  been  thought  by  some  to  exert  a  happy 
efifect,  applied  immediately  on  the  discovery  of  the  accident.  Re- 
peated syringings  are  not  to  be  neglected.  A  case,  occurring  in  the 
person  of  a  physician,  has,  at  this  date  of  writing,  been  treated  by 
the  author,  where  arsenic  had  been  sealed  in  a  tooth-canal  having  a 
drill-hole  through  it  communicating  with  the  alveolus.  As  a  result, 
all  the  bone  forming  the  envelope  of  the  antrum  was  destroyed  and 
came  away. 

Alveolar  necrosis  is  sometimes  induced  by  the  application  of 
chloride  of  zinc,  used  as  an  obtunder  of  dentinal  sensibility,  and  also 
for  the  purpose  of  controlling  the  slight  hemorrhages  caused  by  the 
slipping  of  instruments  in  the  operation  of  filling.  The  first  effect 
is  of  course  upon  the  gum,  inflaming  and  engorging  it,  the  effect 
upon  the  bone  being  secondary.  Nothing  better  than  the  ordinary 
antiphlogistic  applications  can  be  employed.  The  action  here  is 
much  more  tardy  than  in  the  destruction  induced  by  arsenic ;  the 
sequestrum,  however,  is  seldom  very  considerable,  the  alveolus  per- 
haps of  a  single  tooth.  The  action  of  nature  in  the  separation  should 
always  be  awaited. 

Cases  which,  for  want  of  a  better  name,  might  be  termed  anom- 
alous, sometimes  occur.    A  single  instance  may  illustrate.    I.  B.,  an 


NECROSIS.  573 

Irish  laborer,  consulted  for  pain  in  the  two  inferior  incisor  teeth. 
No  caries,  no  periosteal  inflammation,  nothing  indicating  disease, 
was  observable.  The  pain  increased  day  by  day,  until  at  the  end 
of  the  second  week  the  two  teeth  and  their  alveoli  were  found 
detached,  and  were  dissected  from  the  gum.  This  case  is  one  of  a 
very  few  of  the  kind  that  have  been  met  with,  and  which  may  well 
be  termed  anomalies.  The  pulps  are  not  found  dead  if  examined  at 
such  time,  as  under  ordinary  circumstances  one  would  expect  to  find 
them.  There  is  no  soreness  of  the  teeth  on  pressure,  and,  strangest 
of  all,  there  are  none  of  the  common  phenomena  of  inflammation. 
The  practitioner  in  these  cases  must  be  guided  by  such  indications 
as  he  may  be  able  to  seize  upon.  The  condition  is,  in  every  sense 
of  the  word,  strange. 

Necrosis  from  Lack  of  Room  for  Eruption  of  Wisdom-Tooth. 
— This  is  found  most  commonly  associated  with  the  lower  jaw.  The 
close  relationship  of  the  second  molar  with  the  ramus  frequently 
makes  the  egress  of  the  advancing  wisdom-tooth  an  impossibility ; 
hence  an  irritation  resulting  in  inflammation.  The  serious  extension 
of  the  trouble  to  the  bone  is  alwaj^s,  however,  preceded  by  more  or 
less  trismus  and  difficulty  in  deglutition:  thus  every  chance  is  given 
for  an  anticipating  surgical  relief.  This  form  of  necrosis  is  to  be 
looked  for  between  the  seventeenth  and  twenty-fifth  years.  The 
extraction  of  the  second  molar  allows  the  wisdom-tooth  to  fall  for- 
ward ;  thus  the  irritation  is  removed  and  a  cure  effected.  These 
cases  are,  if  rightly  treated,  as  simple  and  harmless  as  they  are 
severe  and  prostrating  if  left  to  chance  or  improperly  managed. 
Extract  the  second  molar  tooth,  and  do  not  attempt  the  removal  of 
the  offending  one, — that  is,  if  such  extraction  threatens  difficulty.* 

*  "  The  advent  of  the  wisdom-teeth  is  very  often  accompanied  by  painful  and 
distressing  symptoms,  that  may  be  protracted  through  many  months,  or  it 
may  be  even  years,  unless  relieved  by  surgical  interference.  These  circum- 
stances arise  from  the  position  occupied  by  the  wisdom-teeth,  so  close  to  the 
joint  of  the  lower  jaw,  where  the  mucous  membrane  is  reflected  from  the  gum 
to  the  cheek  and  fauces,  combined  with  the  very  common  condition  that  the 
jaw  is  not  sufficiently  elongated  backward  to  allow  the  dentes  sapientise  to 
range  in  the  horizontal  series  with  the  other  teeth.  This  mechanical  diffi- 
culty not  only  prevents  the  proper  evolution  of  the  wisdom-teeth,  holding 
them  back  in  their  bony  bed,  but  it  often  perverts  their  direction  of  growth 
and  dislocates  them.  Annoying  and  very  painful  as  are  often  the  symptoms 
attendant  on  difficult  cutting  and  misplacement  of  the  upper  wisdum-teeth, 
they  are  trivial  in  comparison  with  those  which  occur  in  similar  conditions 
of  the  lower. 


574  ORAL  DISEASES  AND  SURGERY. 

Exfoliations  of  laminae  of  bone  are  very  common  after  the  opera- 
tion of  extraction  of  teeth.  Such  scales  vary  in  size  from  that  of 
the  finger-nail  to  a  pin's  head.  They  seldom  require  any  particular 
attention,  coming  away  generally  without  pain  or  trouble  of  them- 
selves. 

"  The  ordinary  misplacement  of  the  upper  wisdom-teeth  is  either  backward 
or  outward,  or  in  both  directions  combined.  When  the  teeth  point  back- 
ward, every  time  the  mouth  is  closed  its  crown  comes  in  contact  with  the 
mucous  membrane,  passing  up  on  the  base  of  the  covonoid  process.  When 
the  direction  is  outward,  which  is  more  common,  the  tooth  projects  into  the 
cheek,  and  when  the  jaws  are  brouglit  together,  a  portion  of  the  mucous 
membrane  in  this  region  is  nipped  and  pinched.  This  is  a  very  painful 
affair;  the  surface  becomes  ulcerated  and  extremely  tender;  there  is  partial 
cicatrization,  and  the  structure  becomes  stiff  and  hard  as  well  as  painful. 

"The  difficulty  which  most  commonly  occurs  with  the  inferior  dens  sapi- 
entiiB  is  attributable  to  insufficient  room  in  the  jaw.  The  tootli  grows  nor- 
mally in  direction  and  in  position  as  regards  its  neighbor  in  front,  but,  from  an 
imperfect  lengthening  of  the  horizontal  ramus  of  the  jaw,  the  birtli  of  the 
crown  is  only  partial  and  incomplete.  The  tooth  is  upright,  but  only  its  front 
cusps  emerge,  while  the  hinder  cusps  are  still  covered  in  with  gum  (see,  for 
lesions,  page  200),  or  the  wall  of  the  bony  loculus  in  which  it  was  formed.  This 
produces  a  terrible  pinching  of  the  mucous  membrane  every  time  the  jaws 
are  brought  together.  Before,  however,  the  enamel  eminences  of  the  tooth's 
crown  make  their  appearance,  the  soft  structures  behind  the  second  molar 
become  much  inflamed,  and  often  suppurate.  The  inflammation  to  which 
the  impaction  and  pressure  give  rise  extends  to  surrounding  tissues  ;  the  cheek 
becomes  stiff' and  painful,  and  deglutition  is  difficult,  and  attended  with  sore- 
throat. 

"  Next  in  frequency  to  the  foregoing  malposition  is  that  in  which  the  wisdom- 
tooth  is  developed  horizontally  forward,  more  or  less.  It  is  attended  often 
with  serious  consequences.  This  direction  is  sometimes  combined  with  an 
inward  leaning,  and  very  rarely  the  crown  of  the  tooth  points  outward. 
This  latter  dislocation  is  very  unusual,  but  the  most  severe  case  of  suffering 
from  displacement  of  the  lower  wisdom-tooth  which  I  have  ever  seen  was  of 
this  variety. 

"The  most  distressing  result,  however,  that  occurs  in  these  cases  is  the 
suppuration  which  sometimes  attends  the  difficult  eruption  of  the  tooth. 
In  slight  cases,  even  where  there  is  no  misplacement  or  want  of  room,  but 
simply  a  restrained  progress  from  an  unusually  dense  or  cartilaginous  over- 
lying gum,  pus  will  be  occasionally  formed.  In  severer  cases,  the  pus  bur- 
rows among  the  areolar  tissue,  around  the  periosteum  of  the  jaw  ;  the  neigh- 
boring soft  structures  become  infiltrated  with  Ij-mph,  and  the  integument  is 
glued  irregularh'  to  the  bone  ;  pus  points  at  different  spots,  often  remote  from 
its  original  source;  and  the  whole  cheek  may  be  undermined  with  sinuses." — 
S.  James  A.  Salter — Holmes. 


NECROSIS.  575 

Syphilitic  Necrosis. — The  hard  palate  seems  particularly  liable 
to  suffer  from  attacks  of  this  specific  disease,  the  venereal  ulcer  of  the 
overlying  soft  parts  and  that  of  the  soft  palate  being  observed  as 
among  the  most  common  of  the  constitutional  affections.  That 
these  ulcers  are,  however,  strictly  venereal,  one  may  be  oftentimes 
led  to  doubt ;  certain  it  is  that  they  appear  and  exist  with  greatest 
virulence  where  mercury  has  been  used  with  unnecessary  freedom. 
Yenereal  ulcers  of  the  mouth  are  of  two  kinds  :  the  superficial,  and 
the  ordinary  ulcer  of  necrosis;  either  of  them  being  represented  in 
general  appearance  by  the  non-indurated  chancre.  The  superficial 
ulcer  may  be  found  both  upon  the  hard  and  soft  palates,  but  is  much 
more  common  to  the  latter.  These  ulcers — as  the  chancres — vary 
in  size  and  character,  being  sometimes  very  amenable  to  treatment, 
at  others  resisting  and  phagedenic,  even  to  the  destruction  of  the 
parts.  Their  treatment  is  to  be  conducted  on  general  principles. 
Few  surgical  conditions  require  nicer  general  judgment  or  more 
attentive  care  ;  it  is,  really,  to  blow  hot  to-day  and  cold  to-morrow, 
and  vice  ver'sa.  As  a  rule,  such  ulcers  are  oblong  in  form,  from  an 
eighth  of  an  inch  to  an  inch  or  more  in  length  ;  more  or  less  exca- 
vated, the  cavity  being  filled  with  a  dirty-white  semi-solid  paste. 
The  truest  practical  comprehension  of  these  cases  is  found,  as  the 
experience  of  the  author  leads  him  to  infer,  in  looking  at  them  as 
one  looks  at  scorbutus. 

Touching  locally  with  the  acid  nitrate  of  mercury,  with  the  nitrate 
of  silver,  or  with  a  mixture  of  equal  parts  of  iodine  and  creasote,  not 
unfrequently  causes  them  speedily  to  assume  healthy  action.  A 
case  will  seldom  be  met  with  in  which  the  internal  exhibition  of  a 
mineral  acid  does  not  seem  to  be  in  some  degree  useful;  and  par- 
ticularly is  this  found  to  be  the  case  where  a  phagedenic  tendency 
exists.  Whatever  remedies,  however,  be  employed,  the  venereal 
basis  of  the  trouble  is  always  to  be  kept  in  mind.  Syrup  of  the 
pyrophosphate  of  iron,  conjoined  with  minute  doses  of  corrosive 
sublimate  and  iodide  of  potassium,  will,  under  certain  conditions, 
compel  such  ulcers  to  disappear  as  if  by  magic;  or  a  combination 
which  may  be  employed  commonly  with  a  happy  effect  is  as  fol- 
lows : 

R. — Hydrargyri  chloridi  corrosivi,  gr.  ij ; 

Potassii  iodidi,  5'j ; 

Syrupi  hypophosphitis,  ^iij  ; 

Syrupl  sarsaparillse  compositae,  §iij.     M. 
Sig. — Tablespoonful  three  times  a  day. 


576  OJiAL  DISEASES  AND   SURGERY. 

The  ulcer  of  necrosis,  looking  like  the  preceding,  differs  from  it 
in  having  the  pasty  mass,  which  constitutes  the  apparent  bottom, 
associated  with  dead  or  dying  bone  beneath.  The  ulcer  in  this  case 
is  not  the  trouble  to  be  cured, — indeed,  could  not  be  cured  while  the 
underlying  disease  exists.  Ulcers  of  this  class,  being  an  attendant 
condition,  are  always,  of  course,  situated  over  the  bones,  generally 
about  the  maxillaiy  and  palate  sutures.  They  are  always  preceded 
by  an  engorged  and  tumid  state  of  the  parts  in  which  they  are 
situated,  indicative  of  the  osseous  trouble  beneath.  The  character 
of  this  tumidity  is  a  matter  of  much  concern,  as  in  proportion  to  its 
solidity  will  generally  be  found  the  extent  of  destruction  in  the  soft 
parts;  the  variability  of  such  destruction  is  seldom,  however,  in 
proportion  to  the  disease  below.  The  author  has  seen  the  whole 
palatine  process  die  while  the  indicative  ulcer  lias  not  been  larger 
than  the  eighth  of  an  inch  in  circumference ;  on  the  contrary,  the 
smallest  sequestrum  will  sometimes  be  found  attended  with  the 
largest  ulceration. 

Incision  into  and  through  this. tumid  engorgement  will  always 
be  found  satisfactory  practice.  The  cuts,  however,  are  to  be  made, 
not  carelessly,  but  with  judgment ;  always  taking  into  consideration 
the  vitality  of  the  part.  Such  incisions,  if  made  through  the  peri- 
osteum, will  frequently  be  found  to  exercise  quite  a  controlling  influ- 
ence on  the  ostitis,  just  as  in  cases  of  ordinary  inflammation,  while 
the  effect  upon  the  soft  parts  is  always  for  good.  The  treatment 
which  should  succeed  the  incisions  is  only  to  be  determined  by  the 
circum.stances  of  each  particular  case ;  not  unfrequently  it  will  be 
found  amply  suflBcient  to  keep  the  parts  well  cleansed,  and  await  the 
coming  away  of  the  sequestrum ;  never,  however,  forgetting  to  meet 
the  constitutional  indication.  In  other  cases,  as  when,  for  example, 
the  phagedenic  type  is  assumed,  the  most  vigorous  and  well-directed 
local  treatment  is  necessitated;  when  cases  are  first  seen  in  the  open 
ulcerated  condition,  semi-indolent,  as  is  frequently  the  case,  no  treat- 
ment seems  superior  to  packing  the  ulcer  with  cotton  saturated  with 
creasote  and  iodine.  Cases  have  come  to  the  writer  for  treatment 
where  the  bone  would  be  found  exposed  to  the  size  of  a  silver  three- 
cent  piece,  and  where  all  the  consequences  of  a  large  opening  into 
the  nares  were  to  be  apprehended,  yet,  by  such  an  application,  re- 
peated ever}^  other  day,  allowing  the  cotton  to  remain  in  the  ulcer 
the  intervening  time,  in  the  course  of  two  weeks  the  denuded  bone 
has  entirely  granulated  over,  and  the  parts  have  remained  perma- 
nently cured. 


NECROSIS.  577 

Breaks  occurring  in  the  hard  palate,  associating  the  oral  cavity 
with  the  nares,  are  easily  remedied  by  a  covering  of  gold  or  silver 
plate.  An  impression  of  the  full  roof  of  the  mouth  is  taken  in  wax ; 
into  this  is  poured  plaster  in  a  cream  form  ;  to  the  cast  thus  pro- 
cured is  fitted  the  plate  of  metal,  supported  by  the  teeth,  or  by 
atmospheric  pressure,  precisely  as  in  the  case  of  a  plate  for  the 
attachment  of  teeth.  Any  reasonably  ingenious  mechanical  dentist 
can  meet  the  indications.   (See  Obturators.) 

In  breaks  of  the  soft  palate  a  simple  wad  of  cotton  may  be  tem- 
porarily^ used  with  a  considerable  degree  of  satisfaction.  Astonishing 
results  in  the  way  of  diminishing  or  closing  these  breaks,  both  in  the 
hard  and  soft  palates,  may  not  unfrequentl}^  be  secured  by  freshening 
the  edges  and  touching  every  second  or  third  day  with  iodine,  zinc, 
dilute  sulphuric  acid,  or  the  compound  tincture  of  capsicum.  Great 
care  is,  however,  to  be  exercised  in  this  practice  not  to  over-stimulate 
the  parts,  very  troublesome  degenerating  inflammations  being  some- 
times the  result  of  an  over-excitement. 

An  ugly  feature  in  the  syphilitic  ulcer  is  its  tendency  to  recur: 
a  palate,  looking  healthy  to-day,  will  assume  to-morrow  an  indo- 
lent relaxed  type,  becoming  semi-yellowish;  some  point  or  other 
will  take  on  a  fatty  look,  and  in  a  few  hours  break  down  into  an 
ulcer.  This  may  recur  a  dozen  times ;  the  explanation  is  to  be  looked 
for  in  the  systemic  condition.  Such  recurrence  of  the  ulceration  may 
extend  over  a  period  of  six  or  eight  months,  in  defiance  of  the  most 
careful  attention.  The  author  has  certainly  found  it  so  in  his  own 
practice,  and  believes  it  to  be  a  common  experience.  The  salt-bath 
will  be  found  in  these  cases  invaluable,  affording,  as  it  does,  increased 
vitality.* 


*  To  Professor  Sigmund,  of  Vienna,  are  we  indebted  for  an  appreciation  of 
syphilitic  manifestations  occurring  where  there  is  associated  with  the  disease 
nothing  of  the  ordinary  history.  Syphilis  of  the  mucous  membrane  of  the 
mouth  and  jaws  ( Wiener  Med.  Wochenschrift)  is  recognized  as  a  second- 
ary or  tertiary  form  of  the  disease  commencing  in  the  genitals  or  region  of 
the  anus.  Those  cases,  on  the  other  hand,  are  rare  in  which  syphilis  most 
undoubtedly,  or  with  a  probability  amounting  almost  to  certainty,  occurs  as  a 
primitive  affection  of  the  oral  mucous  membrane,  especially  the  lips,  and 
thence  extends  to  the  general  system.  Professor  Sigmund,  in  1865,  called 
attention  to  the  inci-easing  frequency  of  affections  of  the  lips  of  primitive 
syphilitic  forms, — indurations,  papulise,  ulceration, — and  this  opinion  has  been 
confirmed  by  subsequent  experience  in  his  own  private  hospital  practice. 
This  observation  has,  in  addition  to  its  importance  with  regard  to  pathology 

3t 


578  ORAL  DISEASES  AND  STJBGERY. 

Mercurial  Necrosis. — Ostitis,  and  exfoliation  from  the  undue 
use  of  the  mercurials,  are  so  common  as  to  have  come  under  the 
notice  of  almost  every  physician.  These  cases  have  generally  a 
history  regular  and  distinctive  in  progress.  First  is  observed  by  the 
patient,  while  the  medicine  is  being  taken,  a  coppery  or  metallic 
taste;  quickly  associated  with  this  is  an  enlargement  of  the  tongue, 
recognized  through  the  indentations  made  by  the  teeth  as  the  organ 
encroaches  on  these  bodies.  The  next  stage  is  a  puflBness  observed 
about  the  necks  of  the  teeth,  commencing  generally  with  the  inferior 
incisors;  the  congestion  of  the  oral  mucous  membrane,  which  soon 
extends  over  the  entire  cavity,  produces  a  sense  of  dryness,  and  not 
unfrequcntly  burning  ;  the  tumefaction,  which  has  now  become  gen- 
eral about  the  necks  of  the  teeth,  assumes  a  livid  color,  and  presents 
a  grayish,  cedematous  surface,  which  extends  more  or  less  widely 
throughout  the  mouth  ;  the  inflammation,  attended  with  its  cacoplas- 
tic  exudate,  next  intrudes  on  the  alveolo-dental  membrane,  and  the 
teeth  soon  become  so  loose  as  readily  to  be  lli"ted  from  their  cavities, 
and  when  so  thrown  off  are  found  covered  with  the  sticky,  grayish 
lymph  in  abundance. 

and  treatment,  a  deep  social  significance.  From  18G1  to  1867  seventy-three 
cases  of  these  primary  aft'octions  of  the  lips  came  under  the  notice  of  Profes- 
sor Sigmund.  Of  these,  thirty-two  were  presented  at  the  hospital,  and  forty- 
one  in  private  practice.  These  seventy-three  cases  of  syphilitic  affections  of 
the  lips  occurred  out  of  5551  patients.  The  disease  was  ohserved  much  more 
frequently  in  the  upper  than  in  the  lower  lip.  The  most  frequent  explanations 
as  to  the  cause  of  its  having  been  contracted  were,  in  males,  smoking,  and  the 
use  of  certain  tools,  and  in  women,  the  rubbing  of  a  spoon  against  the  upper 
lip,  and  also  the  habit  of  holding  between  tlie  lips  thin,  sharp,  and  pointed 
instruments,  such  as  are  used  in  sewing,  arranging  flowers,  drawing,  painting, 
working  in  cardboard,  and  similar  occupations.  It  is  worthy  of  remark 
that  these  affections  of  the  lips  occur  in  all  ranks  of  society.  Professor  Sig- 
mund passes  over  the  special  etiological  i-eports  appertaining  to  these  affec- 
tions, as  they  are  in  many  cases  doubtful,  and,  moreover,  savor  of  .scandal. 
Labio-genital  coitus  could  be  clearly  proved  in  some  cases,  and  in  others 
contagion  by  means  of  paint-brushes,  tobacco-pipes,  drinking-vessels,  etc., 
was  made  out.  The  syphilitic  affections  of  special  importance  to  the  practi- 
tioner are  those  produced  through  kis.sing.  Any  method  of  transferring 
syphilis  to  a  he^iUhy  individual  from  one  previously  affected  at  an  earlier  or 
later  period,  but  evidently,  and  to  a  superficial  observer,  cured  of  the  disease, 
is  of  the  greatest  importance;  and  even  these  methods  have,  according  to 
Sigmund's  experience,  occurred  with  great  frequency,  and  form  a  very  note- 
worthy, but  often  neglected,  mode  of  origin  of  the  affection. 

Interesting  cases  of  specific  inoculation  by  kissing  are  recorded  in  con- 
siderable number  in  American  medical  publications. 


NE  CEOS  IS.  579 

TJncom bated,  the  effect  of  the  metal  passes  rapidly  to  the  alveo- 
lar processes,  this  tissue  seeming  to  undergo  a  process  of  liquefac- 
tion and  absorption.  Necrosis,  when  it  ensues,  may  be  partial  or 
complete.  Many  interesting  cases  of  such  condition  have  come 
under  the  notice  of  the  author,  some  of  which  will  be  found  alluded 
to  in  other  parts  of  this  volume.  Children,  during  the  dentitional 
period,  are  found  most  in  danger  of  mercurial  necrosis,  the  parts 
seeming  preternaturally  susceptible :  the  result,  without  doubt,  of 
the  excitement  related  with  dental  genesis.  When  the  mercurial 
poisoning  is  conjoined  with  the  scrofulous  condition,  the  ravages  are 
found  most  marked.  The  writer  has  known  a  single  two-grain  dose 
of  calomel  in  a  child  of  this  cachexia  to  kill  half  the  lower  jaw.  The 
inflammation  accompanying  mercurial  necrosis  is  apt,  from  its  slough- 
ing tendency,  so  to  destroy  the  neighboring  soft  parts  that  not 
unfrequently  the  mouth  is  permanently  closed,  requiring  for  relief 
plastic  operations  of  the  most  difficult  and  complicated  character  ; 
and,  unfortunately,  even  these  proceedings  are  not  alwaj^s  able  to 
restore  to  the  patient  the  lost  offices  of  the  parts.  (See  02yerations 
on  the  Lips  and  Cheeks.) 

The  state  of  salivation,  so  characteristic  of  the  mercurial  poison- 
ing, comes  on  at  varying  periods,  the  susceptibility  being  influenced 
by  different  conditions  :  the  increase  of  saliva  varies,  also,  from  that 
which  may  scarcely  elicit  attention,  to  a  secretion  which  shall  keep 
the  mouth  of  a  patient  constantly  over  a  vessel.  Persons  occasionally 
are  to  be  met  with  who  will  be  salivated  by  the  simple  smell  of  a 
mercurial ;  there  are  others,  on  the  contrary,  who  appear  in  this 
expression,  at  least,  entirely  unirapressible.  It  would  seem  to  be  a 
just  experience  that  the  mercurials,  as  a  rule,  should  not  be  given 
to  teething  children,  or  to  scrofulous  subjects,  and  assuredly  it  can 
never  be  productive  of  good  to  push  the  medicine,  let  little  or  much 
be  demanded,  beyond  that  point  at  which  its  effects  are  observed 
upon  the  festoons  of  the  gums. 

In  the  treatment  of  mercurial  ulitis  (which  see)  attention  has 
been  called  to  a  practice  by  free  scarification  and  the  local  use  of 
iodine.  Many  cases  of  threatened  necrosis  have  by  these  means 
been  aborted ;  but  very  great  care  is  to  be  exercised,  that  the  low 
vital  force  be  not  still  further  depressed. 

The  treatment  that  applies  to  ulitis  applies  also  to  ostitis. 

In  the  special  treatment  of  the  mercurial,  as  of  any  other  seques- 
trum, it  is  to  be  looked  upon  as  a  matter  of  much  importance  that 
the  dead  piece  be  detached  by  nature  alone,  assisted  by  the  surgeon 


580  ORAL  DISEASES  AND  SURGERY. 

only  as  in  other  paragraphs  described.  Particularly  does  this  seem 
important  in  the  young  jaw,  as  thus  it  may  happen  that  we  shall 
not  disturb,  unnecessarily,  the  germs  of  developing  teeth. 

Much  stress  has  been  laid  by  some  practitioners  on  the  preserva- 
tion of  such  teeth  as  are  associated  with  the  sequestrum,  and  advice 
given  that  incisions  be  made  through  the  soft  parts  that  shall  allow 
the  bone  to  be  drawn  away  from  the  loosened  teeth.  Such  treat- 
ment can  certainly  only  apply  to  very  few  and  peculiar  cases.  As 
a  rule  of  practice,  the  author  is  confident  it  must  be  found  of  little 
signification. 

The  ill  odor  and  putrescence  associated  with  mercurial  necrosis 
are  to  be  antagonized  by  the  free  use  of  antiseptic  injections. 

Necrosis  from  Injuries. — Accidental  injuries  received  by  the 
jaws  are  not  infrequent  causes  of  necrosis.  Having  such  origin, 
the  recognition  and  comprehension  of  the  condition  are  the  appre- 
hension of  the  common  pathological  expression.  Traumatic  influ- 
ences capable  of  provoking  an  ostitis  or  periostitis,  which  may  result 
in  necrosis,  may  be  independent  of  external  wound,  depending 
entirely  on  concussion.*     The  treatment  of  such  cases  is  the  treat- 

*  "  As  a  result  of  injury  there  are  extravasations  into  the  cellular  structure 
of  the  bone  ;  also,  perhaps,  into  tlie  compact  substance,  and  occasionally  under 
the  periosteum.  If  these  ruptures  of  the  vessels  be  so  extensive  that  their 
results  cannot  be  removed  by  collateral  circulation,  which  is  of  difficult  estab- 
lishment in  bone,  part  of  the  bone  will  no  longer  contain  any  blood  ;  this  will 
die,  and,  according  to  circumstances,  we  may  have  central,  superficial,  or  total 
necrosis.  The  portion  of  dead  bone  remains  in  the  organism  as  a  foreign  body, 
but  still  continues  in  continuity  with  the  healthy  bone.  What  becomes  of  bone 
so  destroyed?  Dead  bune  may  be  dissolved  and  consumed  by  granulations. 
Hence  we  should  expect  that  the  elimination  of  the  sequestrum  would  not 
require  any  aid.  From  my  observations,  I  have  no  doubt  that  small  sequestra 
may  be  completely  consumed  by  proliferating  granulations.  Granulations 
that  are  being  destroyed  or  undergoing  cheesy  degeneration  have  no  power 
of  dissolving  bone.  We  have  already  stated,  when  speaking  of  caries,  that 
partial  necrosis  occurs  so  readily  in  atonic,  suppurative,  or  caseous  ostitis, 
just  because  the  inflammatory  neoplasia,  which  so  quickly  breaks  down  again, 
does  not  dissolve  the  bone,  but  leaves  it  to  be  macerated  in  the  body.  But  the 
reabsorption  of  the  sequestrum  has  its  limits:  first,  of  course,  it  ceases  when 
the  bone  is  uncovered,  for  here  the  granulations  have  no  effect ;  it  also  ceases 
as  soon  as  they  secrete  pus  on  their  surface  :  hence  a  sequestrum  resulting 
from  acute  periostitis  is  not  usually  absorbed  at  the  point  where  the  perios- 
teum suppurates,  and  where  pus  forms  during  the  whole  process,  because  it 
does  not  come  in  contact  with  the  granulations;  but  at  all  points  where  the 
sequestrum  must  be  loosened,  reabsorption  commences  from  the  interstitial 


NECROSIS.  581 

ment  of  inflammation  anywhere.  Death  of  the  bone,  in  whole  or  in 
part,  resulting,  the  case  has  the  common  history  of  necrosis. 

ExANTHEMATOus  NECROSIS. — As  a  result  of  the  exanthemata,  it 
occasionally,  though  fortunately  quite  infrequently,  happens  that  a 
subacute  inflammation  of  the  jaw  Qpcurs,  resulting  in  limited  or,  it 
may  be,  extensive  necrosis  of  the  part  affected.  To  this  form  of 
disease,  as  the  recognition  of  its  associations  is  concerned,  atten- 
tion seems  first  to  have  been  directed  by  S.  James  A.  Salter,  of 
Guy's  Hospital,  who  records  twenty-three  cases  as  being  met  with 
in  the  associated  population  of  that  institution.  The  author  in  his 
own  practice  has  now  met  with  four  cases,  all  of  them  being  the 
sequel  to  measles ;  and,  unlike  the  condition  as  it  seems  most  com- 
monly met  with,  the  disease  extensively  involving  the  bone, — the 
lower  jaw  in  three  cases,  the  upper  in  one. 

The  accompanying  cut  is  froiii  a  photograph  of  pieces,  constituting 
the  full  half  of  the  lower  jaw,  removed  from  the  mouth  of  a  German 
boy  six  years  of  age.  The  earlier  history  of  this  case  could  only 
be  procured  to  the  extent  of  learning  that  some  time  after  an  attack 

granulation  masses  forming  on  the  bone.  Lastly,  after  the  sequestrum  is  de- 
tached, if  these  granuhitions  also  produce  pus,  reabsorption  ceases  here  also, 
and  the  sequestrum,  bathed  in  pus,  ceases  to  decrease  ;  the  granulations  of  the 
pus  cavity,  growing  from  all  sides  toward  the  sequestrum,  in  the  course  of 
time  undergo  chemical  change, — they  become  very  gelatinous,  mucous,  and 
..often  undergo  fatty  degeneration. 

"  But  the  sequestrum  must  finally  come  out.  Can  it  do  so  unaided?  This 
does  occur.  Whence  the  power  that  pushes  it  out?  Let  us  suppose  a  central 
necrosis :  a  sequestrum  becomes  detached  from  all  sides ;  then  it  is  consider- 
ably smaller  than  the  cavity  in  which  it  lies.  The  piece  of  bone  is  now  quite 
loose ;  granulations  grow  towaixl  it  from  all  sides  except  from  the  one  where 
the  pus  cavity  opens  externally.  Here  there  is  no  resistance ;  if  the  opening 
be  large  enough,  the  constantly-increasing  granulations  push  out  the  seques- 
trum. But  for  this  to  occur,  there  must  be  certain  mechanical  conditions 
which  are  rarely  fulfilled.  Small  sequestra  are  thrown  off"  spontaneously; 
large  ones,  which  cannot  pass  the  existing  openings,  must  be  removed  arti- 
ficially. 

"The  treatment  of  necrosis  consists  at  first,  simply,  in  keeping  the  fistula 
clean.  Chemical  solution  of  the  sequestruna  is  not  to  be  thought  of.  If  you 
were  daily  to  pour  muriatic  acid  into  the  fistulous  opening,  it  would  affect  the 
newly-formed  osseous  tissue  as  much  as,  if  not  more  than,  it  would  the  seques- 
trum, which  would  be  very  unfortunate,  as  it  must  replace  the  latter.  Hence 
the  mechanical  removal  of  the  sequestrum  is  the  only  thing;  this  should  not 
he  attempted  before  comjylete  detachment.  This  is  a  very  important  rule." — 
Billroth. 


582  ORAL  DISEASES  AND  SUBGERY. 

of  measles  the  child  commenced  to  complain  of  a  sore  mouth,  the 

gums  swelling  as  in  an  attack  of  periodontitis,  the  swelling  after 

a  few  weeks  being  followed  by  the  continuous 

Fig.  2^7.  discharge  of  pus,  which  the  parents  stated 

had  beeq,  troubling  him  for  several  months; 

could  not  say  whether  it  might  be  two  or  four. 

When  first  presented  at  the  clinical  service, 

the  child  was  so  emaciated  that  little  hope 

,,    „     ,        was  entertained  of  saving  its  life  ;  but,  after 

Sequestrum  after  Measles.  °  '  ' 

having  been  placed  upon  vigorous  tonic  med- 
ication for  two  weeks,  taking  iron  and  quinine,  drinking  beer,  using 
salt-baths,  and  having  the  parts  almost  hourly  syringed,  thus 
washing  away  the  offensive  semi-putrid  pus  in  place  of  allowing  it 
as  before  to  pass  to  the  stomach,  and  at  the  same  time  using  local 
means  of  a  stimulating  nature,  the  reaction  was  of  the  most  prom- 
ising character,  and  invited  and  indorsed  the  attempt  to  remove  the 
sequestrum. 

Making  at  a  second  clinic  thorough  examination,  it  was  evident 
that  the  body  of  the  bone  in  mass  was  dead,  and  that  not  the 
slightest  attempt  had  been  made  toward  the  formation  of  any  new 
osseous  structure.  In  this  instance,  all  proper  attempt  was  made 
to  excite  the  production  of  new  bone,  the  necrosed  structure  only 
being  removed  when  to  leave  it  longer  in  its  bed  would  have  been 
to  risk  the  life  of  the  child. 

The  removal  of  the  bone  in  this  case  resulted  in  a  considerable  I* 
immediate  deformity,  but  which  after  two  years  had  so  completely 
disappeared  as  to  be  scarcely  observed,  while  the  natural  motions  of 
the  jaw  seemed  quite  as  good  as  in  other  children.  , 

In  a  second  case,  the  disease  attacked  the  upper  jaw,  resulting  in 
a  repetition  of  small  inflammatory  sequestra,  together  with  the 
crowns  of  the  undeveloped  bicuspidati  of  the  side  affected ;  the  dis- 
ease continuing,  in  defiance  of  treatment,  for  over  a  year,  and  yielding 
finally  only  to  a  summer  spent  upon  the  mountains. 

In  the  treatment  of  these  cases,  nothing  special  seems  demanded, 
unless  it  might  be  that  we  should  be  able  to  recognize  and  admin- 
ister the  specific  for  the  peculiar  poison.  Lacking  such  knowledge, 
the  case  is  to  be  conducted  on  general  principles:  great  cleanliness, 
conjoined  with  stimulating  and  antiseptic  injection,  constitutes  the 
principal  local  demand ;  while  systemically,  the  patient  is  to  be 
supported  under  the  drain  which,  to  a  greater  or  less  extent,  always 
attends  the  process  of  exfoliation. 


NECROSIS.  583 

In  cases  of  slight  signification,  such  as  are  referred  to  among 
others  in  the  foot-note  from  Holmes,  where  the  exfoliated  part  maj 
involve  but  the  edge  of  the  alveolar  process,  so  little  attention  might 
be  demanded  as  to  deny  the  surgeon  even  the  opportunity  to  see 
such  states  of  the  condition.* 

*  "  I  believe  that  the  necrosis  and  exfoliation  of  the  alveolar  process  and 
portions  of  the  jaws  in  children,  consequent  upon  the  eruptive  fevers,  is 
essentially  the  same  as  the  maxillary  necrosis  in  the  victims  of  phosphorus 
fumes,  and  that  it  is  the  result  of  the  local  application  of  a  specific  poison  to 
the  vascular  parts  of  the  teeth.  There  is  this  difterence,  however,  that  in 
the  case  we  are  now  considering  the  poison  is  generated  within  the  individual, 
but  with  affinities  for  certain  structures  and  tendencies  to  action  upon  certain 
organs,  which  give  its  morbid  consequences  an  equally  local  character.  "What- 
ever opinions  may  be  entertained  as  to  the  homological  relations  of  the  several 
tissues  of  the  teeth  to  those  of  the  general  integument,  there  can  be  no  ques- 
tion as  to  their  being  members  of  the  dermal  system,  and  as  such  we  should, 
a  -priori,  expect  that  they  would  share  the  consequences  which  attend  those 
particular  diseases  which  spend  their  chief  force  on  the  skin.  There  is  one 
circumstance,  however,  that  modifies  such  an  anticipation  :  it  is  the  low 
state  of  vitality  of  the  teeth,  and  the  extremely  slight  nutritional  changes 
which  occur  in  them  when  once  they  are  formed,  and  which  must  conse- 
quently remove  them  to  a  great  extent  from  those  transient,  though  potent, 
influences  which  would  destroy  or  morbidly  afiTect  vascular  or  growing  tis- 
sues. But  such  a  qualification  does  not  apply  to  the  conditions  of  the  teeth 
during  their  development.  From  the  time  of  birth  until  the  eighth  or  ninth 
year,  the  jaw-bones  are  the  seat  of  intense  developmental  nutrition  in  the 
formation  of  the  teeth,  and  are  among  the  most  vascular  parts  of  the  body. 
About  the  middle  of  the  period  named,  five  years  of  age,  the  maxillae  con- 
tain no  less  than  forty-eight  developing  teeth  and  developing  tooth-germs. 
It  is  about  this  time  that  the  poison  of  the  exanthematous  fevers  appears  to 
exert  its  most  deadlj^  influence  on  the  dental  system. 

"The  form  of  necrosis  aftecting  the  alveolar  edges  of  the  maxilla,  and 
accompanied  by  the  shedding  of  the  teeth,  which  we  are  now  considering, 
was,  I  believe,  first  recognized  by  myself  (Transactions  London  Pathological 
Society,  vol.  xi.  pp.  209  to  215)  as  one  of  the  sequelae  of  the  exantliemuta, 
and  dependent  necessarily  on  their  previous  occurrence.  Many  isolated  cases 
of  the  aflection  have  been  described,  and  our  museums  contain  specimens  of 
the  sequestra ;  but  the  supposed  relation  of  cause  and  effect  has  not,  so  far  as 
I  know,  been  expressed  before.  (The  earliest  recorded  cases  are  mentioned 
by  Fox  in  his  '  History  and  Treatment  of  the  Diseases  of  the  Teeth,'  p.  112, 
London,  1801.     These  cases,  two  in  number,  occurred  after  smallpox.) 

"This  aft'ection  is  by  no  means  common,  considering  the  almost  universal 
occurrence  of  the  eruptive  fevers.  The  very  large  population  tributary  to 
Guy's  Hospital  has  onlj'  furnished  me  with  twenty-three  or  twentv-four  cases 
during  the  last  nine  years;  and  I  have  reason  to  think  that  even  in  this  I 
have  been  disproportionately  favored. 


If** 


584         •         ORAL  DISEASES  AND   SURGERY. 

Phosphor-Necrosis. — This  is  a  term  applied  to  that  necrosis  of 
the  maxillary  bones  dependent  on  phosphorus-poisoning,  being  a 
disease  peculiar  to  workmen  in  match-factories,  and  confined  here 
almost  exclusively  to  such  as  are  engaged  in  the  processes  of  dip- 
ping and  packing.  How  phosphorus  affects  the  maxillary  bones, 
whether  from  a  systemic  or  a  purely  local  relation,  continues  to  excite 
discussion.     That  persons  possessed  of  carious  teeth  are  alone  af- 

"  The  cases  are  all  .singularly  alike.  A  little  child  has  just  recovered  from 
one  of  the  eruptive  fevers,  most  p.rohably  scarlatina ;  the  case  has  been  in  no 
way  unusual  as  to  its  severity  or  its  course.  Within  six  weeks  or  two  months 
of  the  passing  off  of  the  acute  symptoms,  tenderness  of  the  mouth  is  com- 
plained of,  and  the  mother  notices  fetor  of  the  breath.  Upon  inspecting  the 
mouth,  the  gum  is  seen  to  be  peeling  from  the  edge  of  the  jaw  around  the 
neck  or  necks  of  some  temporary  tooth  or  teeth,  pus  is  discharging,  and  more 
or  less  dead  bone  is  exposed.  The  denudation  of  the  bone, progresses  rather 
quickly  in  depth,  but  usually  not  after  the  first  in  lateral  extent.  The  tem- 
porary teeth  at  the  affected  part  become  loose,  and  often  fall  out.  There  is 
no  swelling,  and  no  ossifying  callus  is  formed  in  the  region  of  the  necrosed 
bone.  In  a  few  weeks  from  the  first  of  these  symjitoms  the  sequestrum  be- 
comes loose,  and  is  easily  removed,  leaving  a  large  gap  and  a  raw,  granulating 
surface,  which  rapidly  heals.  The  necrosis  almost  always  includes  the  bone 
which  constitutes  the  loculi  containing  the  developing  permanent  teeth,  as 
well  as  the  alveoli  of  the  temporary  ;  but  it  does  not  go  further,  and  in  the 
lower  jaw  the  base  of  the  bone  is  very  rarely  affected, — note  clinic  case 
recorded.  I  have  never  seen  such  an  occurreijce.  The  disease  is  frequently 
symuietrical.  When  attacking  the  bone  about  the  temporary  molars  on  one 
side  of  the  jaw  (its  most  common  situation),  it  often  manifests  itself  immedi- 
ately after  on  the  opposite  side,  and  sometimes  in  tl\e  same  regions  of  the  other 
jaw.     The  same  sj-mmctry  is  observed  in  front  of  the  mouth. 

"As  far  as  I  am  aware,  this  affection  only  occurs  after  the  eruptive  fevers, 
and  scarlatina  is  its  most  potent  cause.  In  the  instances  which  .have  been  under 
my  own  care,  two  were  after  smallpox,  five  or  six  after  measles,  and  fifteen  or 
sixteen  after  scarlatina.  There  is,  however,  nothing  in  the  condition  of  the 
mouth  to  indicate  which  has  been  the  precursor.  The  age  at  which  this  affec- 
tion occurs  is  usually  about  five  years  :  from  three  to  eight  are  the  extreme 
limits  I  have  known. 

"  The  issue  of  these  cases  is  simply  comprised  in  the  loss  of  a  certain  amount 
of  bone  with  the  contained  teeth,  and  the  consequent  disfigurement.  As  the 
permanent  teeth  are  lost  with  the  temporary,  the  disfigurement  is  very  great 
when  it  affects  the  incisors  ;  but  when  the  temporary  molars,  and  their  suc- 
cessors, the  bicuspids,  suffer,  the  damage  is  comparatively  slight. 

"  The  treatment  of  these  cases  involves  little  beyond  patience-and  cleanli- 
ness. No  operative  interference  is  indicated  ;  the  extent  of  the  necrosis  asserts 
itself  from  the  first,  and  cannot  be  curtailed.  When  the  sequestrum  becomes 
loose  it  is  to  be  taken  awav." — S.  J.  A.  Salter — Holmes. 


NECROSIS.  585 

fectecl,  seems  sufficiently  verified ;  while,  on  the  other  hand,  as  shown 
first  by  Dr.  Letheby,  of  London,  phosphorus  has  a  systemic  relation, 
as  exhibited  by  its  detection  in  excess  in  the  urine  of  the  poisoned 
patients.  Yon  Bibra  and  Geist,  holding  to  the  theory  of  a  local 
contamination,  direct  attention  to  the  fact  that  "toothache  invaria- 
bhqDrecedes  the  more  severe  affection,"  that  a  carious  state  of  some 
tooth  or  teeth  is  a  "sine  qua  7ion,^'  and  that  "so  long  as  the  teeth 
remain  good  the  affection  does  not  show  itself."  Lorinser,  who  was 
the  first  to  describe  the  phosphorus-disease,  holds  to  the  analogy  of 
the  affection  with  the  mercurial  poisoning,  —  a  view  which  the 
experience  of  the  author  of  this  volume  leads  him  markedly  to 
sympathize  with,  although  it  is  not  to  be  denied  that  such  view 
is  markedly  in  opposition  to  that  which  at  the  present  time  is 
generally  held :  this  common  view  being  that  phosphorous  oxide, 
in  a  low  form,  finds  a  way  to  the  periosteum  through  the  dental 
pulp  canal,  producing,  as  a  result,  this  peculiar  and  specific  inflam- 
mation.*' 

A  jaw,  however,  fretted  and  vascularly  excited  by  teeth  in  a  state 
of  disease,  would  naturally  be  expected  to  be  in  a  more  susceptible 
condition  than  one  strictly  healthy:  hence  it  might  very  well  be 
that  such  special  susceptibility  could  explain  the  attack,  the  natural 
resistive  force  of  the  part  being  to  such  extent  lowered.  Such 
supposition  certainly  tends  to  add  force  to  the  views  of  Dr.  Lorin- 
ser, "that  the  fumes  act  by  infecting  the  blood,  laying  the  primary 
foundation  for  a  disease  which  remains  dormant  until  an  exciting 
cause  fixes  the  spot  for  the  outbreak."  In  proof  of  his  inference, 
attention  is  directed  IJy  Dr.  Lorinser  to  the  peculiar  dirty  sallow, 
combined  with  a  dull,  expression,  together  with  the  gastric  derange- 
ments, which  are  prodromous  to  the  local  affection  ;  expressions 
which  the  author  has  observed  as  characterizing  his  own  patients. 
In  certain  Nuremberg  patients,  however,  mentioned  by  Yon  Bibra 
and  Geist,  these  prodroma  were  not  only  lacking,  but,  on  the  contrary, 
the  majority  were  seen  to  be  of  healthy,  florid  complexions,  which 
some  retained  to  the  last  stage  of  the  disease.  Let  the  true 
expression  of  the  case  be  as  it  may,  a  prophylaxis  always  to  be 
commended  to  workers  in  phosphorus  is  found  in  that  continuous 
attention  to  the  mouth  and  teeth  which  insures  the  most  perfect 
cleanliness,  combined  with  the  immediate  filling  of  every  tooth, 
which  becomes  carious,  thus  preventing  exposure  of  the  pulp.      A 

*  For  arguments,  see  Clinical  Lecture  by  Mr.  Simon,  Lancet,  1850. 


586  ORAL  DISEASES  AND  SURGERY. 

second  prophylaxis  is  one  suggested  by  Mr.  Salter  (see  Holmes), 
who  expresses  the  belief  that  by  keeping  the  atmosphere  of  the 
factories  ammoniuretted,  and  thus  neutralizing  the  acid  vapor,  few, 
if  any,  cases  of  the  disease  would  ever  occur. 

Still  another  means  having  general  commendation  is  found  in  the 
employment  of  a  respirator,  of  which  perhaps  the  best  is  that  de- 
vised by  Mr.  Graham  for  persons  exposed  to  carbonic  acid  vapor. 
This  consists  of  the  mixture,  in  equal  bulk,  of  fresh-slacked  lime 
and  sulphate  of  soda,  worked  into  a  cushion,  through  which  it  shall 
be  eas}'-  to  breathe.  Carbonate  of  magnesia,  used  in  teaspoonful 
doses  twice  each  day,  and  applied  with  all  freedom  locally,  will  be 
found  of  great  service  in  antagonizing  the  acid. 

Outside  of  the  association  of  the  patient  with  phosphorus,  there 
is  nothing  which,  to  an  ordinary  observer,  would  distinguish  the 
incipient  condition  of  this  loathsome  disease  from  a  case  of  severe 
periodontitis. 

The  first  sign  of  a  commencing  phosphor-necrosis  is  found  com- 
monly in  one  or  more  teeth  becoming  sore  to  the  touch,  feeling, 
on  occlusion,  as  if  raised  in  their  sockets ;  in  a  short  time  the  sur- 
rounding gum  begins  to  swell :  in  the  character  of  this  swelling  is 
the  first  distinctive  sign.  It  is  not  the  acute,  firm,  inflammatory 
swelling  of  periodontitis,  or  of  traumatic  ostitis,  but  from  the  begin 
ning  has  a  puffy,  debased,  and  degenerating  look.  One  feels  as  if  he 
might  hesitate  in  adopting  any  very  decided  antiphlogistic  treatment, 
or,  indeed,  in  employing  any  other  than  an  expectant  one.  (See 
case  from  Von  Bibra  and  Geist.) 

Phosphorus  acts  both  on  the  upper  and  the  lower  jaw-bone,  but 
seems  to  have  a  decided  predilection  for  the  lower ;  as  twelve  to 
nine,  perhaps.* 

The  history  of  a  case  of  phosphor-necrosis  might  be  epitomized 
as  follows:  a  degenerative  inflammation  commences  in  the  alveolo- 
dental  membrane,  or  in  the  substance  of  the  bone  ;  the  author  in- 
clines most  strongly  to  the  belief  of  its  commencement  in  the  latter. 
The  degeneration  of  this  bone  progresses  until  its  enveloping  peri- 
osteum—  which  remains  unafi'ected  as  its  vitality  is  concerned — 
separates  from  it.     The  bone  dies  in  bulk,  or  in  part.     In  the  lower 

*  Of  twenty-two  cases  reported  by  Dr.  Loi'enser,  nine  were  of  the  upper 
jaw,  twelve  of  the  lower,  and  one  in  which  both  were  affected.  Of  fifteen 
cases  occurring  in  Nuremberg,  five  were  in  the  upper,  nine  in  the  lower,  and 
one  in  both.  Of  eight  cases  recorded  by  Dr.  Neumann,  three  were  of  the  upper 
jaw,  four  of  the  lower,  and  one  of  both. 


NECROSIS.  587 

jaw,  the  body  alone  commonly  dies,  the  rami  remaining  unaffected. 
In  the  upper,  one  cannot  well  infer  where  the  demarkation  will 
occur.  During  this  process  of  death,  the  periosteum,  particularly  in 
the  lower  jaw,  is  most  active  in  the  reproduction  of  new  bone,  osteo- 
phytes, so  called  ;  this  new  material  exhibiting  markedly  its  endeavors 
to  envelop  and-  replace  the  old.  The  separation  of  the  dead  from 
the  living  bone,  in  the  lower  jaw,  when  the  dead  part  is  at  all  exten- 
sive, will  be' found  most  likely  to  occupy  a  period  of  from  seven  to 
nine  months,  and  is  apt  to  be  attended  with  the  formation  of  many 
sinuses,  both  in  the  mouth  and  about  the  neck,  being  very  ex- 
haustive to  the  patient,  both  on  account  of  the  great  suppurative 
drain  and  the  nauseating  character  of  the  discharge.  All  the  soft 
parts  associated  with  the  affected  jaw,  the  periosteum  perhaps 
excepted,  synipathize  warmlyduring  the  process  of  the  dying  and 
separation,  looking,  indeed,  as  if  very  badly  affected  with  scurvy. 
At  the  period  above  alluded  to,  the  separation  being  completed,  the 
surgeon  may  remove,  with  little  effort,  the  sequestrum ;  the  sinuses 
then  heal,  and  the  parts  may  recover  with  as  little  deformity  as 
attends  the  extraction  of  the  teeth  and  the  ordinary  absorption  of  the 
alveolar  process. 

This,  I  think,  will  be  found  a  common  history  of  the  disease.  The 
author  has  seen  and  treated  many  cases,  and  it  is  thus  that  it  has 
presented  itself  to  his  observation.  It  might  perhaps  be  added 
that  the  teeth,  influenced  by  the  advancing  disease,  loosen  one  by 
one,  so  as  to  make  necessary  their  removal  long  before  the  bone  is 
ready  to  come  away. 

In  phosphor-necrosis  the  death  of  the  bone  seems  to  be  a  result 
of  morbid  porosity,  the  loosening  and  expansion  of  the  structure 
proving  antagonistic  to  its  nutrition;  as  vitality  diminishes,  so,  as  the 
result  of  a  cacoplastic  exudate,  the  periosteum  is  found  to  separate 
itself,  such  secretion  explaining,  in  its  degeneration,  the  character- 
istic abundance  of  fetid  pus.  Indeed,  it  is  to  be  seen  almost  from  the 
earliest  affection  of  the  bone  that  the  periosteum  is  aroused  to 
efforts  for  self-protection;  so  marked  is  this  in  many  instances  that 
attempts  at  the  formation  of  new  bone  separating  the  periosteum 
from  the  dead  tissue  result  in  numberless  osteophytes,  if  indeed  a 
perfect  wall  is  not  secured.  The  writer  has  seen  not  unfi'equently 
the  whole  floor  of  the  mouth,  back  to  the  base  of  the  tongue,  occu- 
pied by  such  new  bone. 

As  is  to  be  readily  recognized,  however,  the  tendency  of  this 


588  ORAL  DISEASES  AND  SURGERY. 

exudate  to  degeneration  is  marked:  thus,  the  osteophytes  are  found 
in  inverse  proportion  to  the  quantity  of  pus.  These  osteophytes, 
in  characteristics,  are  seen  also  to  be  greatly  influenced  by  a  treat- 
ment employed  in  a  case  :  in  the  beginning  they  are,  it  is  to  be 
inferred,  uniform ;  from  such  uniformity  we  see  them  as  slender 
shreds,  in  masses,  and  indeed  in  every  irregularity  of  form  and 
feature ;  decidedly  disposed  also  are  they  to  break  down  and  disap- 
pear, and  this  particularly  where  extreme  cleanliness  is  not  observed 
or  the  s^'stem  at  large  is  left  without  the  support  of  tonic  medica- 
tion. It  is,  indeed,  simply  the  common  history  of  lymph  degenera- 
tion,— an  inability  on  the  part  of  the  plasm  to  the  maintenance  of  a 
self-supporting  organization. 

A  dull,  dirty-yellow  complexion,  as  has  been  remarked,  is  almost 
universally  associated  with  phosphor-necrosis:  this  has  been  variously 
attributed  to  dyscrasia,  to  the  pain,  the  impeded  ingestion,  and  to 
the  immense  drain  made  on  the  system  in  the  progress  of  the  ex- 
foliative process.  The  most  reasonable  hypothesis  is  that  all  these 
causes  are  alike  implicated  :  certain  it  is,  that  to  get  a  patient 
clear  of  such  a  complexion,  all  require  to  be  considered  in  the  treat- 
ment. 

The  tendency  to  the  burrowing  of  pus  in  acute  phosphor- 
necrosis  is  remarkable,  and  to  a  marked  extent  will  such  burrowing 
occur  in  defiance  of  treatment :  if  the  lower  jaw  is  the  seat  of  the 
disease,  the  sinuses  will  riddle  the  neck ;  if  the  upper,  the  antrum 
tends  to  receive  the  pus,  while  in  grave  cases  it  not  unfrcquently 
finds  its  way  to  the  ear  and  the  mastoid  process  of  the  temporal 
bone. 

Salivation  is  another  of  the  marked  characteristics  of  the  condi- 
tion :  the  author  has  had  patients  who  were  compelled  to  have  a 
handkerchief  constantly  at  the  mouth  to  receive  the  drainage. 
Another  source  of  discomfort  resides  in  vomiting:  particularly 
does  this  tend  to  occur  in  the  morning,  the  result  of  the  pus  swal- 
lowed during  the  night.  Fever,  diminution  of  appetite,  and  de- 
rangement of  the  bowels  follow  the  progress  of  the  disease,  and,  if 
not  vigorously  combated,  are  apt  to  end  in  an  inanition  fatal  to  the 
patient. 

The  sequestra  of  phosphor-necrosis  in  the  lower  jaw  look  some- 
what like  pieces  of  rotten  sponge,  being  almost  as  light  and  porous; 
this  arises  from  the  suppuration  and  discharge  of  the  primary 
exudate  which  was  the   cause   of  the  original   enlarijement :    the 


NECROSIS.  589 

organic  material  being  all  discharged,  nothing  remains  but  the  cell- 
riddled,  inorganic  structure,  hence  the  brittleness. 

Treatment. — The  treatment  pursued  in  phosphor-necrosis  is  to 
consist  in  the  employment  of  means  which  shall  circumscribe  as  much 
as  possible  the  disease,  which  shall  hasten  the  process  of  limited 
death  and  the  accruing  separation,  and  which  shall  support  the 
patient  undeir  the  drain  to  which  he  is  necessarily  subjected. 

When  a  case  presents  in  its  incipiency,  that  is,  simulating  a  de- 
veloping periodontitis,  we  commence  the  local  treatment  just  as  we 
would  that  of  the  periodontitis.  If  the  inflammation  has  about  it 
anything  of  a  healthy  acuteuess,  we  limit  as  much  as  possible  all  ex- 
ternal irritation,  by  softening  in  the  gas-flame  or  by  the  stove  a  piece 
of  gutta-percha,  and  moulding  it  over  some  opposite  tooth,  or  tooth 
farthest  removed  from  the  seat  of  trouble ;  a  mouthful  of  cold  water 
hardens  this  cap,  and  thus  occlusion  against  the  sore  tooth  or  teeth 
is  prevented.  A  dose  of  Epsom  salts  or  other  saline  cathartic  is 
ordered,  and  a  sinapism  is  applied  to  the  back  of  the  neck.  A  hot 
pediluvium  is  found  sometimes  to  act  very  happily  as  a  derivative; 
or  a  diaphoretic,  such  as  the  spirits  of  Mindererus,  may  serve  a 
very  good  end.  Depletion  by  leeches,  however,  has  never  seemed 
to  the  author  to  be  an  indication :  the  affection  has  its  very  origin 
in  asthenia. 

If  we  first  see  the  case — and  this  is  most  apt  to  occur — when  a 
discharge  has  made  passage  for  itself  by  opening  through  the  gum 
at  the  neck  of  a  certain  tooth  or  teeth,  we  immediately  make  a  free 
incision  through  the  soft  parts  down  upon  the  bone,  and  s^a-inge  the 
parts  thoroughly  with  some  medicated  water,  stimulating  or  antisep- 
tic, or  both,  as  indicated.  Having  the  parts  well  cleansed,  we  stuft" 
the  wound  which  has  been  made,  with  cotton  or  sponge.  This  is 
repeated  the  next  day  and  the  next,  until,  particularly  as  the  syring- 
ing is  concerned,  it  may  be  absolutely  necessary  to  repeat  it  a  dozen 
or  twenty  times  per  diem,  the  progress  of  the  disease  being  so 
marked  by  discharge  and  offensiveness.  As  day  by  day  the  cotton 
or  sponge  stuflfing  is  renewed,  it  is  insinuated  gently  between  the 
separating  periosteum  and  bone.  This  manipulation  will  be  found 
to  hasten  the  separation  wonderfully,  and  expedite  the  cure  of  the 
case. 

It  might  here  be  asked,  perhaps,  by  some  one,  "  Is  not  this  pro- 
cess of  working  off  the  periosteum  an  unsurgical  proceeding,  com- 
pelling an  extension  of  the  disease  beyond  that  which  would  have 
been  the  result  if  left  to  itself?"     The  author  can  only  answer  from 


590  OBAL  DISEASES  AND  SURGERY. 

his  own  experience  in  different  modes  of  treatment,  and  say  that  he 
is  perfectly  satisfied  that  this  is  not  the  case,  and  that  the  result 
is  for  the  good  of  the  patient  in  every  way:  the  portion  of  bone 
destined  to  die  has  the  destruction  markedly  hastened  ;  the  sooner 
the  death,  the  sooner  the  separation;  the  sooner  the  separation 
and  exfoliation  of  the  sequestrum,  the  less  exhaustion  to  the 
system. 

The  compound  tincture  of  capsicum,  with  an  excess  of  myrrh  and 
an  addition  of  the  permanganate  of  potash,  is  an  excellent  wash  for 
the  mouth  in  these  cases.  Cold  water,  with  a  little  salt  and  mag- 
nesia dissolved  in  it,  can  be  used  ad  lihiium. 

The  sinuses  which  are  so  apt  to  form  upon  the  neck,  in  defiance 
of  all  treatment,  and  which  greatly  annoy  by  their  discharge,  are 
most  comfortably  treated  with  dressings  of  patent  lint.  Once  formed, 
it  is  a  waste  of  time  to  attempt  the  healing  of  them  :  they  will  only 
get  well  when  the  source  of  offense  in  the  dead  bone  is  removed. 

It  has  been  remarked  that  the  death  is  limited  in  the  lower  jaw 
to  the  body  of  the  bone,  the  horizontal  portion,  the  demarkation  oc- 
curring at  the  angle.  This,  in  the  majority  of  instances,  will  be  seen 
to  be  the  case,  particularly  if  the  treatment  has  been  properly  directed. 
Seven  months  has  been  found,  in  the  practice  of  the  writer,  the 
minimum  required  for  the  course  of  the  disease,  nine  months  the 
more  common  time,  and  fifteen  the  maximum,  although  this  latter 
does  not  accord  with  German  experience,  cases  being  reported  of 
two  years  and  a  half  standing.  The  drain  during  most  of  this  time 
is  immense,  the  patient  requiring  the  most  generous  tonics  and  sub- 
stantial fare.  Attention  to  the  repair  of  this  wear  and  tear  is,  per- 
haps, of  greater  consequence  than  any  local  treatment;  certainly,  if 
one  could  not  have  both,  his  chances  would  be  best  with  the  former. 
Both  are  to  be  esteemed  as  of  vital  consequence.  To  commence, 
however,  with  the  ordinary  medicinal  tonics,  is  ill  advised.  One 
cannot  well  keep  on  with  them,  and  by  employing  them  in  the  begin- 
ning of  the  disease  we  lose  their  powerful  assistance  at  a  time  when 
every  help  is  found  weak  enough  at  the  best.  Good  underdone 
roast  beef  is  quite  enough  for  the  first  two  or  three  months ;  then 
an  addition  may  be  made  of  generous  malt  liquors,  together  with 
the  salt-bath.  The  latter  portion  of  the  time  will  demand  iron, 
quinine,  brandy.  The  hemorrhages,  sometimes  so  profuse,  are  held 
very  well  in  check  by  the  exhibition,  once  or  twice  weekly,  of  five- 
drop  doses  of  tincture  of  Erigeron  Canadense. 

The  period  at  which  a  sequestrum  is  i-eady  to  be  taken  away  can 


NECBOSIS.  591 

only  be  known  by  repeated  examination,  the  proper  treatment  being 
to  wait  always  until  the  separation  is  complete,  be  such  time  longer 
or  shorter.  Nothing,  the  author  is  satisfied,  is  gained  by  expediting 
the  removal  through  operative  proceedings,  as  by  breaking  away 
the  bone,  using  the  chain-saw,  etc.,  while  the  risk  to  life  is  very 
considerable.  To  wait  patiently,  keeping  the  system  equal  to  the 
demand  on  it,  is  the  surgeon's  highest  duty;  to  do  more  is  to  do 
harm. 

The  removal  of  the  bone  is  always  to  be  effected  from  the  inside ; 
it  does  not  seem  that  an  outside  incision  would  ever  be  found  neces- 
sary. If  the  opening  along  the  gum,  obtained  in  the  treatment,  be 
not  great  enough,  it  is  easily  enlarged  to  an  extent  desired. 

A  step  preliminary  to  the  removal  of  the  body  of  the  lower  jaw 
is  its  divi-sion  at  the  symphysis.  This  is  most  easily  accomplished 
by  means  of  the  straight-cutting  forceps.  It  is  better  to  cut  little 
by  little,  from  above  downward,  than  to  crush  through  the  bone  with 
a  single  cut ;  it  does  not  hurt  or  shock  nearly  so  much.  The  opera- 
tion is  not  a  severe  one,  seldom  demanding  the  patient  to  be  ether- 
ized, yet  it  is  generally  enough  to  be  borne  at  one  sitting. 

To  take  away  the  bone,  no  instrument  is  found  better  than  the 
ordinary  tooth  forceps,  such  as  is  in  common  use  for  the  extraction 
of  the  inferior  incisors  and  bicuspidati.  With  such  forceps,  com- 
plete control  of  the  part  is  secured,  and  the  removal,  as  a  general 
thing,  easily  effected. 

A  trouble  frequently  encountered,,  and  one  which,  undistinguished, 
would  prove  confusing  and  deceptive,  consists  in  the  grasping  of  the 
sequestrum,  when  extensive,  by  the  lateral  overlying  tissues, — not 
by  the  new  bone,  but  by  the  indurated  soft  parts.  The  writer  recalls  a 
case  which  he  once  had  under  treatment,  where,  the  dead  bone  being 
thus  held,  the  practitioner  bad  been  waiting  for  the  separation  a 
period  of  over  two  years,  being  deceived  entirely  as  to  the  condition 
of  the  part.  To  satisfy  one's  self  as  to  the  condition,  pass  a  small  hook 
under  the  bone,  and  lift :  if  the  bone  yields  springy,  it  is  only  thus 
held,  and  may  with  safety  be  pulled  through  ;  if,  on  the  contrary,  it 
is  firm  and  unyielding,  it  is  to  be  left  alone, — separation  has  not  yet 
taken  place. 

In  the  reproduction  of  the  new  bone,  which,  at  the  period  for  the 
removal  of  the  old,  should  be  found  to  have  obtained  such  character 
as  to  keep  up  perfectly  the  shape  of  the  parts,  the  observer  will  be 
struck  with  the  excess  deposited  along  the  middle  line  of  the  mouth  : 
it  seems,  oftentimes,  as  if  the  floor  was  a  mass  of  bone, — which, 


592  ORAL   DISEASES  AND   SURGERY. 

indeed,  it  really  is.     It  will  not  be  found  necessary,  however,  to  do 
anything  with  this  excess,  nature  taking  all  proper  care  of  it. 

Phosphor-necrosis  attacking  the  upper  jaw  seems  not  so  much  to 
be  dreaded  as  that  associated  with  the  lower.  It  is  seldom  so  for- 
midable in  its  nature  or  so  destructive  in  its  progress,  the  disease  in 
these  parts  having  been  seen  to  run  its  whole  course  with  an  entire 
absence  of  acute  action.  A  portion  of  bone  dies,  and  the  surround- 
ing soft  parts  seem  utterly  indifferent.  One  would  scarcely  know 
anything  abnormal  was  going  on,  were  it  not  for  the  indication  given 
in  the  loosening  of  the  teeth ;  these  drop  out  somewhat  as  they 
would  out  of  the  dried  skull,  while  the  soft  parts  eventually  present 
the  appearance  of  shrinking  away  from  the  bone,  which  structure 
becomes  fully  exposed, — as  dry  and  lifeless,  apparently,  as  that  of 
any  dead  skull.  This,  however,  is,  of  course,  not  the  common  his- 
tor}'.  The  inflammatory  action  is  of  the  same  type  as  that  associ- 
ated with  the  disease  in  the  lower  jaw,  but  more  limited  in  extent 
and  consequence,  and  nmch  more  susceptible  to  remedial  measures. 
A  bad  feature  consists  in  a  niarked  tendency  to  recurrence  of  the 
trouble  ;  but  this,  perhaps,  will  mostly  be  found  within  the  control 
of  the  surgeon.  The  removal  of  a  sequestrum  here  is  a  trifling 
matter,  comparatively  little  dissection  letting  the  piece  pass.  If  the 
bone  seems  grasped  by  the  contracting  soft  tissue,  the  easiest  plan 
of  removal  will  be  found  in  the  introduction  between  the  parts  of 
pellets  of  cotton  :  these  quickly  swell,  and  thus  effect  loosening. 

At  a  Medical  Congress  in  Zurich,  Switzerland,  Professor  Billroth, 
in  citing  his  experience  with  phosphor-necrosis,  remarked  that  in 
attacking  the  upper  jaw  it  seemed  to  act  with  greater  and  more 
destructive  force,  and  was  more  unmanageable. 

The  author  does  not  know  how  to  reconcile  these  differences  in 
clinical  observation,  unless  an  explanation  may  be  found  in  the  im- 
plied greater  tendency  to  return  which  exists  on  the  part  of  the  dis- 
ease when  situated  in  the  upper  jaw.  In  the  lower  jaw,  the  full 
part  that  is  to  die  seems  impressed  from  the  beginning, — that  is  to 
say,  a  certain  portion  seems  predestined,  and  it  dies  in  defiance  of 
all  you  may  do.  Not  that  the  evidence  of  the  disease  is  general 
over  all  the  involved  part  from  the  beginning :  on  the  contrary,  the 
incipient  stage  is  markedly  localized;  but  then,  day  by  day,  and 
week  by  week,  the  trouble  extends  over  the  apparently  predeter- 
mined or  preimpressed  part.  When  the  death  occurs,  it  is  a  single 
death ;  and  when  the  piece  is  cast  off,  there  is  not  apt  to  be  any 


NECROSIS. 


593 


Fig.  228. — Appearance  of  Patient 
WITH  Phosphor-Necrosis. 


renewal  of  the  trouble.  The  sequestrum  of  the  upper  jaw,  on  the 
contrary,  is  generally  small,  some  portion,  most  likely,  of  the  alve- 
olar process ;  but  unless  the  treatment  is  of  the  most  supporting  and 
speciSc  kind,  it  is  apt  to  repeat  itself,  again  and  again;  but  your 
treatment  will  be  responded  to  here,  and  thus,  with  care  and  atten- 
tion, you  have  the  amount  of  destruction  comparatively  under  con- 
trol. If  it  is  found  more  unmanageable  in  Zurich,  then  the  means 
would  not  seem  to  be  so  well  adapted  to  the  end  as  those  here  em- 
ployed, or  otherwise  the  circumstances  must  be  different. 

Again,  at  the  same  Congress  frequent  resections  are  commended. 
To  be  so  commended,  they  must,  of  course,  have  been  found  to 
answer  a  good  purpose.  The 
patients  who  have  their  jaws 
resected  for  phosphor-necrosis 
disease  in  this  country  gener- 
ally die,  or,  if  happily  they 
escape  death,  they  do  not  find 
their  disease  cured  without  an 
inflammatory  sequestrum  at  last. 

This  case  (Fig.  228),  taken 
from  life,  represents  a  patient  as 
he  appeared  with  the  disease 
five  months  in  progress.  At 
the  end  of  eight  months  the 
writer  removed  the  jaw  at  the 
articulation  :  the  loss  was  very 
fully  repaired  at  the  date  of 
operation,  the  parts  having  excellent  motion. 

An  important  objection  to  the  operation  of  resection,  even  were 
the  question  of  life  not  involved,  is  the  great  resulting  deformity. 
Let  nature  take  her  course,  and  of  this  there  may  be  little  or  none. 
A  late  patient  was  a  gentleman  for  whom  the  author  removed — or 
rather  from  whose  mouth  nature  cast  out — the  whole  body  of  the 
inferior  maxilla,  and  no  one  might  tell  whether  it  had  been  a  case  of 
necrosis  or  of  simple  extraction  of  all  the  inferior  teeth,  with  the  con- 
sequent alveolar  absorption,  so  perfect  has  been  the  repair  in  accord- 
ance with  the  destruction.  The  objection  that  this  new  bone  keeps 
up  the  trouble,  by  becoming  involved  in  the  diseased  action,  is  not 
according  to  the  experience  of  the  author.  If  it  becomes  involved, 
it  would  seem  to  imply  that  it  has  not  been  properly  cared  for.  Care- 
ful and  properly  repeated  syringings  with  water  medicated  with 

38 


594  ORAL  DISEASES  AND  SURGERY. 

iodine  and  creasote  will  protect  it.  This  experience  does  not,  how- 
ever, include  the  isolated  osteophytes ;  these  do  without  doubt  incline 
to  degeneration  and  decomposition,  but  by  care  the  many  may  be 
stimulated  to  a  self-supporting  combination  to  which  the  periosteum 
becomes  what  it  was  to  the  bone  exfoliated. 

It  is  certainly  most  unfortunate  that  in  the  case  of  the  upper  jaw 
no  osseous  repair  seems  attempted,  but  it  is  not  the  experience  of 
the  author  that  the  horrible  deformities  mentioned  by  various 
writers  are  at  all  common.  Local  and  systemic  stimulation  combined 
with  a  tonic  treatment  insures  more  or  less  attempt  at  supporting 
the  surrounding  parts  by  an  exudate  which  assumes  a  fibro-carti- 
laginous  aspect,  and  which  will  assume  the  duties  of  the  structure 
lost,  to  very  good  purpose. 

In  loss  of  structure  in  the  lower  jaw  the  most  vigorous  efforts 
are  seen  to  exist  on  the  part  of  the  periosteum  almost  from  the  be- 
ginning to  reproduce  the  impressed  part,  disproving  to  such  extent, 
as  it  would  seem,  the  deduction  of  Dr.  Geist,  that  the  phosphor- 
ostitis  is  secondary  to  periostitis,  for  assuredly  is  it  the  case  that 
under  no  circumstances  of  excitation  does  this  tissue  exhibit  higher 
vitality.  That  this  secondary  deposit  differs  from  the  original  bone, 
in  possessing  an  excess  of  organic  structure,  implies  perhaps  only 
that  the  deficiency  in  inorganic  substance  has  its  explanation  in  the 
presence  of  the  corroding  acid  of  the  disease.  That  the  capsule 
of  new  bone  is  so  frequently  found  to  atrophy  may  have  similar 
explanation  with  the  primary  osteophytic  degenerations,  requiring, 
if  not  a  local,  yet  a  constitutional  care.  A  suggestion  made  by  Mr. 
Salter  that  the  new  bone  be  supplied  with  function  by  using  it  as 
soon  as  possible  as  a  base  for  artificial  teeth  may  be  found  to  have 
in  it  much  practical  import.* 

*  As  a  study,  having  associated  with  it  a  post-mortem,  and  which  must 
indorse  the  hints  furnished  in  the  body  of  this  paper,  attention  is  directed  to 
the  following,  taken  from  Von  Bibra  and  Geist.  The  reader,  however,  should 
be  impressed  with  the  inadvisability  of  any  treatment  by  depletion. 

"Barbara  Keim,  aged  twenty-two,  a  well-made,  under-sized  brunette;  of 
healthy  constitution;  menses  regular,  no  morbid  predisposition,  nut  scrofu- 
lous; had  been  engaged  for  four  years  in  a  lucifer  manufactory  in  counting 
the  matches,  which  at  that  time  was  done  in  the  .drying-room. 

"During  the  first  three  and  a  half  years  she  remained  perfectly  healthy; 
during  the  last  half  year  she  had  occasionally  suffered  from  toothache  on  the 
light  side  of  the  lower  jaw,  but  to  this  she  paid  little  attention,  as  she  had  ■ 
formerly  been  subject  to  toothache,  and  had  lost  several  teeth  by  caries.     As 
the  pain  only  occurred  periodically,  she  was  not  induced  to  quit  her  occupa- 


NECROSIS.  595 

tion.  At  the  beginning  of  February,  1843,  the  toothache  on  the  right  side 
of  the  lower  jaw  became  more  severe,  it  ceased  to  be  limited  to  the  carious 
teeth,  and  extended  through  the  whole  jaw,  over  the  cheek,  and  even  to  the 
temporal  region  and  the  neck.  At  the  same  time  considerable  febrile  dis- 
turbance, with  occasional  rigors,  supervened,  accompanied  by  swelling  of 
gums  and  cheek,  with  erysipelatous  redness  of  the  latter.  February  4,  she 
was  admitted  into  the  hospital.  The  examination  showed  the  right  cheek 
much  swollen,  and  very  tense  towards  the  eye,  the  mouth,  the  chin,  and  neck; 
the  tension  most  considerable  in  the  vicinity  of  the  lower  jaw.  Pain  deep- 
seated,  throbbing,  piercing,  concentrated  at  the  angle  of  the  jaw,  and  radiat- 
ing thence  over  the  adjacent  soft  parts.  Extreme  tenderness  on  pressure. 
The  gums  of  the  diseased  side  of  the  jaw  much  swollen,  tense,  darkened,  and 
tender ;  the  mucous  membrane  of  the  cheek  equally  so ;  between  the  angle 
of  the  jaw  and  the  first  molar,  thick,  fetid  pus  of  a  phlegmonous  character 
oozed  out  on  pressure. 

"  The  first  and  fourth  molars  on  the  right  side  of  the  lower  jaw  were 
carious ;  the  other  molars  deficient,  incisors  and  canine  sound.  Tongue 
furred,  bitter  taste,  pain  in  forehead,  oppression  at  epigastrium,  ructus,  nau- 
sea, constipation,  inflammatory  fever. 

"Ordered,  an  emetic,  fifteen  leeches  at  angle  of  jaw,  a  laxative  to  follow, 
and  a  gargle  of  oxymel  and  aq.  flor.  sambuci. 

"  Evacuation  of  a  large  quantity  of  acid  and  acrid  saburra.  Relief  of 
general  sjmptoms  ;  gradual  progress  of  local  affection.  The  swelling  of 
gums  increased,  became  more  tense,  extended  to  the  soft  palate;  dysphagia 
and  salivation  supervened  ;  and  the  jaw  became  almost  immovable.  Sup- 
puration increased,  pus  laudable,  but  fetid.  Ordered  eight  leeches  to  angle 
of  jaw.  Ung.  hydr.  with  ol.  hyosc,  to  be  rubbed  in,  nitre  mixture,  iodine 
externally  and  internally.     Poultices. 

"  During  the  second  week,  the  four  incisors  and  one  molar  became  loosened, 
suppuration  ichorous  and  rusty,  gums  softened  and  livid,  formation  of  sinuses 
on  the  external  and  internal  surface,  through  which  the  probe  reached  the 
bone,  which  appeared  in  part  rough,  in  part  smooth.  Pain  lessened,  extreme 
exhaustion.  Commencement  of  cough  and  hectic  symptoms.  In  the  pro- 
gress of  the  disease,  increased  retraction  of  gums  from  the  alveolar  surface, 
fresh  abscesses,  increased  discoloration,  and  burrowing  sinuses,  so  that  the 
entire  side  of  the  jaw  was  exposed  to  the  probe,  both  externally  and  internally. 
The  bone  appeared  almost  entirely  detached  from  the  soft  parts,  floating  in 
an  excessively  fetid  sanious  fluid.  The  first  and  fourth  molar  and  the  four 
incisors  either  fell  out  or  were  taken  away  by  the  fingers.  The  swelling  of 
the  cheek,  over  which  there  was  a  frequent  livid  flush,  remained  undiminished, 
but  it  yielded  more  to  pressure,  apparent  fluctuation  at  one  or  two  points, 
but  no  pointing  of  abscess  externally.  The  lips  and  ej-elids  became  oedema- 
tous ;  and  during  the  latter  weeks  of  the  patient's  existence,  the  left  cheek 
also  became  painful  and  swollen.  The  affection  had  thus  reached  the  stage 
of  gangrenous  destruction  of  the  soft  parts ;  the  pain  ceased  almost  entirely  ; 
but  there  was  a  gradual  increase  of  the  hectic  symptoms;  and  in  spite  of 
tonic  and  antiseptic  treatment,  the  patient  died  on  the  seventy-third  day  of 
the  illness,  worn  out  by  hectic. 


596  ORAL  DISEASES  AND  SURGERY. 

"Post-mortem,  eight  hours  after  death. 

"  Extreme  emaciation,  right  cheek  swollen,  soft,  livid.  On  being  detached 
from  the  edge  of  the  lower  jaw,  a  rusty,  grumous,  highly  offensive,  and 
greasy  fluid  exuded.  Neither  gums,  periosteum,  nor  muscles  of  the  cheek 
were  distinguishable.  All  those  soft  parts  appeared  to  be  dissolved  in  the 
grumous  fluid,  which  was  inclosed  in  the  integument  of  the  cheek  as  in  a 
pouch.  The  right  half  of  the  inferior  maxilla  perfectly  denuded,  and  void 
of  all  connection  with  the  soft  parts  in  this  grumous  mass,  so  that  after  divi- 
sion of  the  capsular  ligament  it  was  extracted  without  the  least  difl[iculty. 
In  the  lungs,  tubercular  deposition ;  but  neither  softening  nor  suppuration, 
which  accorded  with  the  previous  symptoms,  as  nothing  had  indicated  the 
second  and  third  stages  of  pulmonary  phthisis.  No  tubercles  in  the  mesen- 
teric glands.  Anaemic  and  flabby  state  of  the  chief  organs,  the  heart,  liver, 
spleen,  and  kidneys;  the' blood  in  the  large  veins  very  thin  and  blackish. 

"Descri-ption  of  inferior  maxilla. — On  the  external  and  internal  surface  of 
the  ramus  of  the  right  side,  there  is  a  deposition  of  new  osseous  matter,  partly 
accumulated  in  large  masses,  partly  in  small  isolated  portions  round  the  neck 
of  the  articulating  process,  without  affecting  the  glenoid  surface,  extending 
along  the  external  and  internal  surfaces  of  the  condyle  and  the  coronoid  pro- 
cess to  the  angle  of  the  jaw.  The  deposit  is  extremely  delicate  at  the  neck, 
and  where  it  forms  the  detached  portions,  increasing  in  compactness  and  size 
as  it  descends,  so  as  to  present  a  thickness  of  from  a  line  to  a  line  and  a  half 
at  the  angle  of  the  jaw,  where  the  deposits  of  the  two  sides  join,  without  at 
all  points  being  in  actual  contact  with  the  bone  of  the  jaw.  On  the  inner  sur- 
faces of  the  maxilla  the  deposit  extends  almost  to  the  chin.  At  the  alveolar 
processes  of  the  incisors,  there  are  three  larger  insular  deposits.  On  the  ex- 
ternal surface  this  new  formation  reaches  to  the  fourth  molar,  and  there  are 
smaller  deposits  on  the  alveolar  process  of  the  right  carious  tooth.  There 
are  also  two  delicate  deposits  on  the  left  side  in  the  region  of  the  first  and 
second  molar. 

"  The  new  deposit  is  everywhere  but  loosely  attached  to  the  subjacent  bone, 
has  no  organic  connection  with  it;  the  thinner  portions  may  be  easily  removed 
by  the  nail,  and  the  surface  of  the  exposed  bone  appears  perfecth'  smooth. 
Some  parts  of  the  former  decay,  and  separate  spontaneously,  which,  however, 
is  not  the  case  in  the  more  compact  mass  attached  to  the  angle  of  the  jaw. 
The  more  delicate  portions  of  the  deposit  present  a  porous  structure,  resem- 
bling a  fine  sponge,  an  appearance  due  to  the  innumerable  vascular  orifices. 
In  proportion  as  the  deposit  descends,  and  becomes  more  compact,  the  spongi- 
ness  diminishes,  and  at  the  angle  of  the  jaw  the  surface  is  much  smoother, 
and  the  vascular  orifices  less  numerous.  The  new  deposit  is  partly  of  a  dingy 
gray  color,  partly  having  a  yellowish  or  a  brownish  or  reddish  tinge.  The 
alveolar  process,  at  the  right  and  left  last  molar,  is  perforated,  and  looks  cor- 
roded. The  alveoli,  which  are  open,  present  nothing  abnormal.  The  bone 
of  the  maxilla  itself  presents  throughout  a  smooth  surface,  even  under  the 
new  formation,  and  must  be  considered,  so  far  as  external  signs  serve  as  an 
indication,  as  a  perfectly  sound  bone." 

As  a  clinical  case,  having  in  it  a  valuable  lesson,  the  author  may  add  the 
following  from  his  own  practice.     On  a  date  forgotten,  a  father  presented  for 


NECROSIS.  597 

treatment  a  daughter  with  the  communication  that  she  had  a  very  sore  tooth, 
and  that  her  wedding  being  appointed  for  the  third  following  day,  it  was 
hoped  she  might  be  cured  by  that  time.  Examining  the  mouth  of  the  patient, 
a  periosteally  diseased  tooth  was  at  once  recognized,  but  the  gum  about  it 
was  so  debased  and  puffy  as  to  imply  almost  to  a  certainty  more  extensive 
disease  and  to  suggest  phosphor-poisoning,  the  fact  of  which  poisoning  the 
information  that  the  girl  worked  in  a  match-factory  at  once  verified.  To  tell 
this  patient  that  her  wedding  must  be  deferred  for  a  year,  and  to  explain  the 
long  tedious  treatment  necessary  for  her  cure,  was  to  provoke  a  fainting-fit 
and  quite  a  disagreeable  scene. 

These  people,  both  father  and  daughter,  were  quite  intelligent,  and  much 
trouble  was  taken  to  explain  the  principles  of  treatment  and  cure,  and  par- 
ticularly to  make  understood  the  great  demand  necessarily  to  be  made  on  their 
patience  and  endurance. 

Seven  months  this  case  was  under  care,  being  seen  every  third  day,  and 
treated  precisely  as  suggested  in  the  body  of  this  chapter.  At  the  end  of 
this  period  the  body  of  the  bone  was  found  loose  in  its  new  envelope,  excepting 
that  the  ramus  of  one  side  had  not  quite  separated.  This  objection  to  an 
immediate  removal  was  explained,  and  directions  enjoined  to  continue  treat- 
ment for  another  month,  when  in  every  probability  the  whole  jaw  would  be 
capable  of  being  lifted  away  without  trouble  or  pain  ;  while  at  the  same 
time  the  preservation  of  the  contour  of  the  face  would  be  secured  by  the  new 
jaw  which  was  being  formed.  Ill  advised,  the  girl,  losing  faith  in  a  treat- 
ment which  necessarily  seemed  to  be  going  from  bad  to  worse,  discontinued 
her  visits.  When  next  heard  from,  she  had  invited  the  operation  of  expe- 
diting the  removal  of  the  sequestrum  by  a  saw-cut  at  the  line  of  demarkation, 
and  which  resulted  in  death  within  a  week. 


CHAPTER    XXIX. 

WOUNDS   OF   THE    MOUTH   AND   ASSOCIATE   PARTS. 

Wounds  of  the  mouth  and  associate  parts  have,  of  course,  the 
signification  of  wounds  in  general.  Thus,  some  are  of  an  incised 
character,  being  slits  or  incisions  made  accidentally  or  purposely  by 
sharp-edged  instruments.  Some  are  lacerated,  contused,  or  torn, 
being  made  by  dull  and  blunted  instruments ;  some  are  punctured, 
being  made  by  pointed  but  not  sharp  instruments ;  some  are  pene- 
trating, as  when  the  offending  agent  passes  through  the  lip  or  cheek 
into  the  oral  cavity.  A  wound  may  be  of  a  compound  or  compli- 
cated nature,  as,  for  example,  in  the  case  of  blows  or  falls,  which, 
while  they  cut  and  contuse  the  lip  or  cheek,  break,  at  the  same  time, 
the  teeth  or  fracture  the  jaw;  gunshot  injuries,  lacerating  or  simply 
puncturing  the  soft  parts,  comminuting  the  hard  ;  bites  of  rabid 
animals,  introducing  a  virus  ;  syphilitic  inoculations,  etc.  Compli- 
cations may  also  be  considered  as  embracing  hemorrhage  and  shock 
as  primary  associations ;  inflammation,  with  its  varied  phenomena, 
erysipelas,  pyaemia,  tetanus,  etc.,  as  secondary  associations. 

Every  wound  presents  a  first  indication.  If  an  individual  receives 
a  hurt  which  covers  the  injured  part  with  earth  or  other  foreign 
substance,  such  substance  is  to  be  washed  or  taken  away  as  the 
primary  step.  If  hemorrhage  is  the  feature,  arteries  are  to  be 
ligated,  or  other  necessary  means  taken  to  control  such  bleeding. 
If  shock  be  present,  this  is  the  most  immediate  feature,  and  is  first 
to  be  combated.  If  a  rabid  or  poisonous  animal  has  inflicted  the 
wound,  the  destruction  of  the  virus  is  a  first  indication. 

Foreign  Particles. — To  remove  earth  or  similar  foreign  parti- 
cles, no  better  means  can  be  employed  than  the  simple  sponge  and 
water.  Holding  the  injured  part  over  a  basin,  squeeze  water  upon 
it  from  the  sponge  ;  if  the  particles  are  not  washed  away  with  the 
sponge  closely  applied,  let  it  be  lifted  away,  and  the  water  allowed 
to  fall  from  a  distance.  It  is  not,  as  a  rule,  at  all  necessary  to 
permit  the  sponge  to  come  directly  in  contact  with  a  wound.  Bodies 
which  may  not  be  washed  away,  no  matter  what  their  character, — 
(598) 


WOUNDS   OF  MOUTH  AND   ASSOCIATE  PARTS.     599 

splinters,  shot,  balls,  particles  of  powder,  spiculae  of  bone,  etc., — are 
to  be  removed  with  forceps,  scoop,  or  other  convenient  means,  the 
rule  being  to  allow  nothing  to  remain  that  may  interfere  with  the 
process  of  repair. 

Hemorrhage. — A  first  matter  to  consider  in  hemorrhage  is  its 
character.  Is  it  arterial,  venous,  or  capillary?  An  arterial  hemor- 
rhage is  known  by  its  scarlet  color,  and  by  issuing  from  the  wound 
in  jets.  Hemorrhage  from  a  vein  is  dark,  and  has  a  gradual  and 
regular  flow.  Capillary  hemorrhage  is  an  oozing.  Arterial  hemor- 
rhage may  require  that  the  bleeding  vessel  shall  be  ligated.  To  do 
this,  it  is  only  necessary  to  sponge  away  the  blood  until  the  vessel 
can  be  plainly  seen  ;  it  is  then  to  be  taken  hold  of  by  the  forceps,  or 
caught  in  the  tenaculum,  and  a  strand  of  waxed  silk  thrown  around 
it.  In  tying  this  silk,, one  must  be  careful  that  he  shall  not  break 
his  strand  at  either  side  of  the  knot ;  also  that  the  tightening  shall 
be  sufficient  to  cut  the  middle  and  inner  coats.  To  prevent  tearing 
the  vessel  from  its  bed  by  the  breaking  of  the  ligature,  the  rule  of 
holding  the  thumbs  upon  the  strands  close  to  either  side  of  the  artery 
is  always  to  be  observed. 

After  llgating  a  vessel,  one  end  of  the  ligature  may  be  cut  off  and 
the  other  brought  out  from  between  the  edges  of  the  wound  ;  this 
allows  of  an  easy  future  removal  of  the  knot. 

Torsion  of  a  bleeding  artery  is  a  favorite  mode  of  treatment  with 
many  surgeons.  The  end  of  the  vessel  is  to  be  caught  by  the  for- 
ceps and  twisted.  The  author  of  the  mode  suggests  that  the  torsion 
be  continued  until  the  end  is  twisted  off. 

Acupressure  is  another  and  a  very  common  method  of  treatment. 
A  steel  or  gold  needle  is  passed  beneath  the  vessel  in  such  manner 
as  to  tightly  compress  it  against  the  neighboring  parts. 

Pressure  by  pad  and  bandage,  when  a  hemorrhage  about  the  face 
will  not  yield  to  simpler  means,  is  a  very  satisfactory  way  of  treat- 
ment, and  one  entirely  reliable.  AH  the  vessels  of  this  region  rest 
upon  a  bony  floor,  and  all  of  them,  at  certain  points,  are  sufficiently 
superficial  for  the  purpose, — the  facial,  at  the  notch  in  the  inferior 
maxillary,  in  front  of  its  angle;  the  temporal,  just  in  front  of  the 
ear  above  the  zygomatic  process ;  the  supraorbital,  at  the  notch  in 
the  orbit;  the  infraorbital,  at  the  foramen  below  the  border. 

A  bandage  of  common  application  for  any  of  these  vessels  is  the 
crossed  or  knotted  circular.  A  glance  at  the  drawing  (Fig.  229) 
will  exhibit  the  manner  of  its  employment. 

It  is,  however,  very  seldom   that  any  of  these  operations   are 


600  ORAL  DISEASES   AND   SURGERY. 

necessary  for  the  arrestation  of  hemorrhage  about  the  face  or  mouth. 
Cold  water  thrown  over  the  bleeding  part  from  a  sponge  will  fre- 
quently cause  such  a  contraction,  both  of  vessels  and  tissues,  as  to 
control  it  quickly  enough.  If  water  alone  will  not  answer  the  pur- 
pose, let  alum  be  added,  as  much  as  the  water  will  dissolve.  If  even 
this  should  not  answer  the  end,  use  a  syringe,  throwing  a  jet  from 
Fig.  229. — Crossed  or  a  distance  directly  upon  the  part  bleeding ; 
Knotted  Bandage.  this  last  will  seldom  disappoint.    Monsel's 

solutions,  so  warmly  lauded  for  their  styp- 
tic qualities,  have  exhibited  to  me  more 
ill  results  than  I  have  ever  met  with  from 
any  dozen  other  articles.  If  used  at  all, 
I  think  the  bleeding  points  should  be  alone 
touched ;  but  of  one  thing  any  one  using 
them  may  be  assured  :  if  the  application 
does  not  control  the  hemorrhage  instantly 
and  permanently,  he  will  have  increased 
his  trouble  manifold. 
A  hemorrhage  that  is  venous  or  capillary  will  seldom  require 
more  than  an  application  of  cold  water.  If  this  or  the  alum-water 
should  fail,  astringent  medicines  may  be  administered  internally. 
Of  the  anti-hemorrhagic  medicaments,  none  has  ever  stood  me  in 
better  purpose  than  a  tincture  of  the  Erigeron  Canadense  ;  one  drop 
to  be  given  in  a  teaspoonful  of  water  each  minute.  This  dose  seems 
like  a  very  small  one,  but  a  larger  administration  has  always  ap- 
peared to  me  to  do  harm  rather  than  good.  Opium  and  lead  I  have 
used  with  much  satisfaction,  one  grain  of  the  former  to  two  of  the 
latter  ;  three  or  four  of  such  pills  may  be  administered  at  intervals 
of  from  one  to  two  hours  each,  if  found  necessary.  (See  Hemor- 
rhage, p.  423.) 

SHOCK. 

Depression  generally  attends,  to  a  greater  or  less  extent,  the  recep- 
tion of  all  wounds.  Surgeons  divide  shock  into  primary  and  sec- 
ondary, or  that  which  is  immediate  upon  the  reception  of  the  injury, 
and  that  which  does  not  exhibit  itself  until  some  later  period.  Shock 
is  prostration  :  this  may  be  simply  of  a  nervous  nature,  implying 
functional  disturbance;  or  it  may  be  organic,  implying  injury  of 
some  vital  part;  it  may,  again,  have  the  twofold  relation. 

In  my  own  experience  I  have  found  few  things  more  important  to 
observe  than  the  differences  between  real  and  apparent  shock.     One 


WOUNDS   OF  MOUTH  AND  ASSOCIATE  PARTS.     601 

person,  heavy  and  lymphatic  in  temperament,  shall  receive  an  in- 
jury mortal  in  its  character,  and  yet,  as  the  immediate  or  primary 
shock  is  concerned,  afford  less  evidence  of  such  injury  than  another 
of  nervous  temperament  who  may  suddenly  be  called  to  look  upon 
his  wound.  Mistakes,  in  such  conditions,  have  very  frequently  re- 
sulted fatally  to  the  persons  most  concerned.  An  article  in  the  val- 
uable work*  of  Prof  H.  H.  Smith,  of  the  University  of  Pennsyl- 
vania, so  tersely  considers  this  important  matter  that  I  am  sure  no 
language  could  give  it  better  expression. f 


*  Principles  and  Practice  of  Surgery,  by  Henry  H.  Smith,  M.D.,  etc. 

f  "  In  the  normal  or  healthy  condition  of  the  body,"  says  Professor  Smith, 
"  each  function  is  so  well  and  accurately  performed  as  to  pass  unnoticed  by 
an  ordinary  observer.  The  moment  attention  is  called  by  marked  inconve- 
nience, to  any  part,  that  moment  its  healthy  action  is  changed,  the  duration 
of  the  disordered  action  varying  greatly.  When  only  interrupted  for  a  lim- 
ited period,  the  function  may  be  again  performed  without  any  appreciable 
alteration ;  but  when  the  interruption  is  of  some  hours'  duration,  the  pre- 
servative action  of  life  may  be  so  impaired  as  to  result  more  or  less  quickly 
in  death. 

"  When  any  injury  of  a  part  is  of  sufficient' magnitude  to  produce  a  marked 
derangement  in  the  function  of  the  local  nerves,  reflex  action  may  induce 
such  a  depression  of  the  general  powers  of  life  as  will  result  in  the  state  tech- 
nically designated  as  Prosiration  or  Collapse.  This  depressed  condition  is 
especially  noticeable  in  the  disturbance  of  the  ganglionic  system  and  its  effects 
on  the  circulatory  apparatus,  and  is  shown  either  immediately  or  some  hours 
or  even  days  after  the  receipt  of  the  injury.  When  apparent  within  a  short 
time  after  the  injurj',  the  condition  is  designated  as />wmec?ja^e  or  Primary 
Shock;  but  when  not  developed  until  several  hours  or  days  subsequently,  it  is 
known  as  Insidious  or  Secondary  Shock.  In  both  there  is  a  common  feature 
of  depression,  the  degree  of  which  depends  on  the  violence  and  extent  of  the 
injury,  or  the  character  and  position  of  the  part  injured. 

"  In  the  lighter  forms  of  primary  shock  the  patient  trembles,  is  pale,  faint, 
and  with  an  anxious  countenance  ;  and  much  the  same  symptoms  are  said  by 
Longmore*  '  to  be  witnessed  in  the  horse,  mortally  hit,  no  less  than  in  his 
rider  ;  the  graver  the  injury,  the  graver  and  more  persistent  is  the  shock.'  In 
marked  cases  the  pulse  is  small  and  feeble  or  fluttering  ;  the  respiration  some- 
what oppressed  and  sighing  ;  the  skin  pale  and  moist,  with  cold  perspiration  ; 
while  nausea,  vomiting,  and  hiccough  are  also  seen,  and  in  some  cases  there 
are  often  well-marked  convulsions.  The  disorder  of  the  nervous  system  varies 
greatly,  and  is  sometimes  rather  the  result  of  mental  than  of  corporeal  action, 
as  in  a  pistol-shot  in  an  extremity  not  involving  important  parts,  but  in  which 
the  patient's  mind,  having  been  impressed  with  the  danger  to  which  he  was 
exposed,  continues  for  some  time  subsequently  to  influence  his  corporeal  func- 

*  On  Gunshot  Wounds,  Phila.  edit.,  p.  45. 


602  ORAL  DISEASES  AND  SURGERY. 

Virus. — If  a  rabid  dog,  or  other  animal,  bite  the  part  we  are  con- 
sidering, or  any  part, — if  a  poisonous  serpent  strike  its  fang,  or  even 

tions.  The  violence  of  the  symptoms  of  primary  shock,  in  connection  with 
moderate  injuries,  will  depend  often  on  the  temperament  of  the  patient,  and 
his  mental  condition  at  the  time.  If  excited  by  passion,  quite  severe  injuries 
will  often  pass  unnoticed,  while  in  cool  blood  the  very  idea  of  a  simple  opera- 
tion will  suffice,  in  some  persons,  to  produce  nervous  prostration  of  a  marked 
character,  so  much  so  as  readily  to  induce  syncope.  In  gunshot  wounds  of 
the  lower  extremities,  and  in  severe  railroad-injuries,  and  extensive  burns, 
the  symptoms  of  shock  are  usually  most  marked.  In  these  cases  the  patient 
sometimes  loses  his  consciousness  entirely,  and  becomes  faint,  exhibiting  great 
mental  disquietude,  with  absence  of  thought,  and  giving  foolish  answers,  or 
incoherent  mutterings.  The  skin  is  covered  by  a  cold  sweat,  and  is  pale  and 
flabb}' ;  the  muscles  are  all  relaxed  ;  the  arm,  if  raised,  drops  as  if  paralyzed  ; 
the  sphincters  of  the  bladder  and  anus  permit  the  escape  of  urine  and  feces, 
and  of  this  the  patient  is  unconscious.  Kespiration  is  much  disordered,  and 
barely  perceptible  ;  the  pulse  hardly  to  be  felt ;  the  action  of  the  heart  feeble, 
or  sometimes  so  faint  as  only  to  be  heard  by  applying  the  ear  to  the  chest ; 
the  eyes  have  a  vacant  expression  ;  the  eyelids  when  raised  remain  open  from 
want  of  action  in  the  orbicularis  palpebrarum;  the  jaw  drops,  and  the  hear- 
ing is  temporarily  lost,  or  is  stimulated  only  by  loud  noises — the  patient  re- 
maining in  this  semi-dead  condition  for  a  period  which  varies  greatly,  as 
from  a  few  minutes  to  hours,  according  to  the  extent  of  the  shock.  In  the 
milder  forms,  with  sufficient  consciousness  remaining,  there  is  only  a  mental 
commotion,  so  as  to  permit  easj'  reassurance;  but  in  the  more  marked  degree 
this  is  often  difficult,  death  sometimes  supervening  without  reaction,  though 
most  frequently  a  certain  amount  of  reaction  is  established  and  consciousness 
returns,  or  prostration  again  supervenes  and  the  patient  dies.  When  a  limb 
is  shot  or  torn  away,  or  the  body  badly  scalded,  the  local  paralysis  induced 
by  the  injury  apparently  prevents  its  immediate  perception  by  the  brain,  and 
in  numerous  instances  the  patient  has  been  ignorant  of  the  loss  of  a  limb  until 
his  attention  was  called  to  it.  But  as  soon  as  the  brain  becomes  cognizant  of 
the  injury,  and  the  stage  of  depression  or  shock  sets  in,  these  apparently  dis- 
tant local  injuries  are  attended  by  the  symptoms  just  enumerated,  though 
they  are  seen  less  quicltly  than  when  the  injury  involves  the  trunk  or  head. 
"When  the  symptoms  of  shock  are  marked,  serious  internal  injury  may  be 
diagnosed  even  though  not  apparent  at  the  moment.  In  most  cases  of  marked 
shock  the  power  of  deglutition  is  more  or  less  impaired  for  the  time,  while 
even  in  the  milder  instances  the  patient  experiences  such  difficulty  in  swal- 
lowing as  will  cause,  when  the-attempt  is  made,  the  sudden  spasmodic  effort 
designated  as  a  'gulp,' or  the  portion  partially  swallowed  is  ejected  with 
symptoms  of  strangulation,  often  evidently  of  a  hysterical  character.  When 
consciousness  is  not  so  much  impaired,  the  patient  may  be  able  to  control  the 
pharyngeal  muscles,  yet  those  of  the  extremities  will  be  so  imperfectly  regu- 
lated as  to  cause  the  limbs  to  tremble  as  if  with  fright,  or  as  if  exhausted  by 
violent  exercise. 


WOUNDS  OF  MOUTH  AND  ASSOCIATE  PARTS.     603 

if  the  loose  kiss  of  the  chancrous  lip  inoculate, — a  first  indication  is 
to  get  clear  of  the  poison.     How?     It  is  now  very  generally  ac- 

"  Duration. — The  duration  of  the  primary  shock  is  very  varied.  In  mild 
cases  it  disappears  rapidly,  the  patient  quickly  recovering  ;  the  depression 
or  the  disposition  to  syncope  passing  away  and  leaving  him  feeble  in  his  cir- 
culation as  well  as  in  his  general  strength.  But  in  more  marked  cases,  as  in 
the  crushing  of  a  limb  by  a  railroad-train,  or  by  machinery,  or  a  round  shot, 
the  collapse  lasts  for  several  hours,  when,  the  powers  of  life  rallying,  7-eaction 
occurs,  and  there  is  a  renewal  of  the  ordinary  functions  of  the  nervous 
system,  noted  in  the  circulation,  which  now  tends  to  excessive  action  as  much 
above  the  healthy  standard  as  the  depression  was  below  it. 

"  This  reaction  after  the  shock  of  injury,  if  not  regulated  by  appropriate 
treatment,  frequently  creates  a  hyper semia  or  congestion  of  the  blood-vessels, 
and  soon  develops  inflammation  and  traumatic  fever.  To  prevent  this,  and 
keep  the  reaction  from  exceeding  its  proper  bounds,  and  yet  raise  the  flagging 
powers  of  life,  is  the  important  indication  to  be  accomplished  in  the  treat- 
ment. 

"Treatment  of  Primary  Shock. — In  mild  cases  of  shock,  a  few  encour- 
aging words,  a  mouthful  of  water,  or  wine  and  water,  with  judicious  expla- 
nations of  the  limited  extent  of  the  injury,  will  often  suffice ;  but  in  marked 
cases,  when  the  patient's  consciousness  is  impaired,  and  his  powers  of  deglu- 
tition are  temporarily  paralyzed  or  much  weakened,  our  means  of  reviving 
the  action  of  the  system  must  at  first  be  limited  to  such  remedies  as  can  be  ap- 
plied without  being  introduced  into  the  mouth.  The  best  plan  of  treatment 
is,  therefore,  to  dash  cold  water  on  the  head  and  face ;  to  excite  artificial 
respiration  by  gently  and  quickly  compressing  the  costal  cartilages,  or  by  the 
'  Eeady  Method'  of  Marshall  Hall ;  by  applying  stimulating  vapors,  as  strong 
ammonia,  to  the  nostrils  ;  by  exciting  the  nerves  of  the  skin  by  sinapisms 
applied  especially  to  the  epigastric  and  cardiac  regions,  and  to  the  extremi- 
ties; by  applying  heat  to  the  surface  of  the  body  through  hot  bricks,  bottles 
of  hot  water,  etc.,  and  by  rousing  the  dormant  action  of  the  sympathetic 
nerves,  through  the  bowels,  by  administering  stimulating  enemata,  as  oleum 
terebinthinse,  infusion  of  capsicum,  etc.,  sufficiently  diluted  with  water  or 
mucilage  to  prevent  the  development  of  rectal  infiammation.  About  gij  of 
ol.  terebinthinffi  in  a  pint  of  soap-suds  or  salt  water  usually  suffices. 

"When  by  the  continued  use  of  these  remedies  the  patient  regains  suffi- 
cient consciousness  to  be  able  to  swallow,  or  when  the  depression  has  not  gone 
so  far  as  that  just  alluded  to,  stimulants  may  be  cautiously  introduced  into 
the  stomach.  Of  these,  such  should  be  selected  as  are  not  likely  to  induce 
congestion  of  the  cerebral  vessels ;  hence  ten  or  fifteen  drops  of  the  aromatic 
spirits  of  ammonia  in  a  little  water,  repeated  every  ten  or  twenty  minutes, 
answers  better  than  alcoholic  liquors,  unless  the  latter  are  given  in  moderate 
quantities,  and  their  intoxicating  tendency  oarefully  guarded  against. 

"As  the  pulse  begins  to  respond  to  these  measures,  the  use  of  both  external 
and  internal  stimulants  should  be  omitted,  the  natural  tendency  being  to  a 
reaction  that  must  be  restricted  to  proper  limits.     Should  the  pulse  become 


604  ORAL  DISEASES  AND   SURGERY. 

cepted  that  the  immediate  application  of  solid  nitrate  of  silver  to  the 
parts  wounded  will  neutralize  these  poisons,  or  that,  at  any  rate,  it 

full,  hard,  and  frequent,  so  as  to  indicate  febrile  reaction,  cold  drinks,  cold 
sponging,  saline  cathartics,  and  arterial  sedatives,  such  as  five  drops  of  the 
tincture  of  veratrum  viride  every  hour,  may  be  necessary, — the  powerful 
action  of  the  latter  remedy  requiring  its  cautious  administration,  so  as  to 
repress  but  not  depress  too  much  the  action  of  the  circulation.  The  strong 
tincture  of  aconite  root,  in  doses  of  two  drops,  or  of  tincture  of  digitalis,  in  the 
dose  of  ten  drops  every  two  hours,  for  a  few  hours,  may  also  be  advanta- 
geously used,  if  carefully  watched  and  omitted  as  soon  as  the  force  and  fre- 
quency of  the  pulse  indicate  their  sedative  action.  By  judicious  attention  to 
the  proper  action  of  the  circulation  in  these  cases,  carefully  stimulating  the 
patient  when  in  the  collapsed  or  depressed  condition,  and  inducing  sedation 
when  the  reaction  becomes  excessive,  patients  may  be  rallied  from  the  shock 
of  injury  and  subsequently  treated  as  demanded  by  the  peculiar  nature  of  the 
case.  In  that  mild  degree  of  shock,  sometimes  seen  in  patients  who  have 
been  shot  by  a  bullet  in  the  extremities,  or  struck  on  the  testicles  or  in  the 
pit  of  the  stomach,  which  is  characterized  by  faintness,  trembling,  and  men- 
tal anxiety,  a  little  cold  water,  or  wine  and  water,  with  a  few  wqrds  of  hope 
as  to  the  result  of  the  injury,  often  suffices. 

"  In  many  severe  injuries,  and  especially  in  those  which  involve  the  main 
trunks  of  large  nerves,  or  the  spinal  cord,  or  a  great  extent  of  the  surface  of 
the  body,  there  is  sometimes  noted,  at  varying  periods  after  the  reception  of 
the  injury,  a  train  of  symptoms  of  a  marked  character,  that  are  very  justly 
spoken  of  as  those  of  the  secondary  or  insidious  shock  of  injury. 

^^  Symptoms. — The  symptoms  of  insidious  shock  are  often  so  masked  as  to 
escape  the  attention  of  an  inexperienced  observer  until  they  are  so  far  devel- 
oped as  to  render  it  difficult  to  rally  the  forces  of  the  patient.  Thus,  when  a 
limb  has  been  torn  off  by  a  cannon-ball,  or  in  a  rolling-mill  or  a  thrashing- 
machine,  or  by  a  railroad-train,  the  patient  not  unfrequently  appears  to  be 
almost  unconscious  of  the  severity  of  his  injury,  the  local  paralysis  being  so 
perfect  as  to  prevent  the  excruciating  suffering  that  such  an  injury  would 
otherwise  create.  In  the  case  of  a  railroad-accident,  by  the  collision  of 
opposing  trains  on  one  of  our  railroads,  I  saw  a  young  man  who  had  his  arm 
cut  off  near  the  shoulder-joint,  with  so  little  suffering  as  to  be  unaware  of  the 
extent  of  the  injury  till  his  clothing  was  removed.  By  great  care  he  subse- 
quently recovered. 

"  In  numerous  instances  in  the  experience  of  all  surgeons,  such  patients 
have  presented  the  following  symptoms:  immediately  after  the  injury  they 
are  remarkablj'  cool,  self-possessed,  and  as  if  endowed  with  indomitable 
fortitude  ;  the  pulse  is  often  barely  accelerated ;  the  respiration  quiet  and 
natural ;  the  skin  pleasantly  warm  ;  the  mind  clear,  though  perhaps  a  little 
torpid,  but  apparently  with  perfect  consciousness.  In  some  cases  patients  have 
been  known  to  walk  or  ride  some  distance,  evidently  unconscious  of  injury, 
till  suddenly  faintness  supervenes,  and  they  fall  to  the  ground,  and  die  in  the 
course  of  an  hour,  more  or  less.     In  other  cases,  where  the  external  wound 


WOUNDS   OF  MOUTH  AND   ASSOCIATE  PARTS.     605 

will  so  alter  the  condition  of  the  wounded  part  as  to  slough  off  the 
offending  agent  and  prevent  its  absorption.     If  an  escharotic  is  not 

or  injurj'  is  more  evident,  they  will  give  directions  for  their  removal,  arrange 
their  bed,  business,  etc.,  reply  to  questions  rationally,  and  with  great  compo- 
sure ;  yet,  as  has  been  well  described  by  the  late  Dr.  George  McClellan,* 
they  will  present  a  countenance  that  is  altogether  unnatural,  having  'an  in- 
quiring, anxious  look  about  the  forehead,  eyes,  and  upper  portions  of  the  face, 
while  all  about  the  mouth  is  smiling  and  composed.'  In  addition  to  which, 
'  they  look  with  a  stare  of  alarm  and  suspicion  at  the  surgeon  when  his  atten- 
tion is  called  to  them.' 

"  After  this  period  of  treacherous  calmness  has  existed  from  three  to  eighteen 
hours,  the  expression  suddenly  changes  ;  the  lips  become  livid  or  deadly  pale; 
the  blood  leaves  the  surface  of  the  body  ;  the  pulse  flutters  and  becomes  too 
rapid  to  count;  the  respiration  is  short  and  panting  ;  a  great  sense  of  oppres- 
sion distresses  the  patient,  and  he  sinks  slowly,  as  if  suffocated,  or  dies  as  if 
struck  by  lightning.  In  these  cases  the  foundations  of  life  are  undermined, 
and  the  paralysis,  which  was  at  first  limited  to  the  part  injured,  suddenly 
extends  to  the  nervous  centres,  and  life  is  arrested  by  the  want  of  proper 
nervous  force. 

^^ Prognosis. — The  prognosis  in  cases  of  severe  injury,  in  which  the  patient 
is  thus  unconscious  of  suff"ering,  cannot  be  too  guarded,  the  patient  not  being 
out  of  danger  from  insidious  shock  until  after  the  lapse  of  forty-eight  hours 
of  perfect  tranquillity.  In  the  majority  of  such  cases,  when  secondary  shock 
supervenes,  death  ensues. 

"  Treatment. — The  treatment  of  secondary  or  insidious  shock  should  be 
chiefly  prophylactic,  special  attention  being  given  to  the  preservation  of  the 
powers  of  the  nervous  system  by  the  administration  of  food  and  stimulants, 
while  all  muscular  action  on  the  part  of  the  patient  should  be  carefully 
guarded  against. 

"  In  many  cases  it  will  be  useful  to  give  milk-punch,  beef-tea,  quinine,  car- 
bonate of  ammonia,  chalybeates,  etc.,  as  often  as  possible,  until  some  evidence 
is  shown  of  their  effect  upon  the  circulation.  Then,  while  the  patient  is 
strictly  confined  to  the  recumbent  position,  stimulating  frictions  should  be 
made  along  the  spine,  cold  applied  to  the  head  if  it  becomes  hot,  pediluvia  or 
hot  bottles  applied  to  the  feet  if  cold,  and  access  given  to  a  sufl&cient  amount 
of  fresh  air  in  the  chamber  to  favor  active  respiration,  while  the  patient  is  at 
the  same  time  kept  warmly  covered  up  in  bed.  By  such  means  the  occurrence 
of  secondary  shock  may  be  prevented ;  but  should  it  supervene,  nothing  but 
powerful  stimulants  to  the  spine,  or  the  administration  of  ether,  brandy,  cap- 
sicum, etc.,  with  the  free  use  of  beef-essence,  atfords  a  hope  of  checking  the 
rapid  prostration  that,  if  not  watched,  will  carry  off"  the  patient.  In  every 
case  of  serious  laceration  of  a  limb,  opening  a  large  joint,  tearing  nerves,  etc., 
cautious  watching  of  the  pulse  can  alone  guard  against  the  development  of 
insidious  shock.  If  the  patient  is  disposed  to  sleep,  let  the  pulse  be  noted,  and 

*  Principles  and  Practice  of  Surgery,  p.  IS.    Phila.,  1848.    Edited  by  Dr.  Jno.  II.  B.  McClellan. 


606  ORAL  DISEASES  AND  SURGERY. 

at  hand  (and  this,  at  the  moment,  would  be  not  unlikely),  such  a 
wound  may  be  cut  away.  Suction  is  also  an  admirable  prophylactic 
(not  as  the  chancre  inoculation  is  concerned:  there  would  be  here 
no  immediate  hurry)  for  most  poisonous  introductions.  The  danger 
to  the  person  sucking  such  a  wound  would  be  very  trifling;  any 
danger  at  all  depending  on  a  casual  abrasion  that  might  at  the 
time  be  present  about  the  mouth  or  lips.  Excision  of  bitten  parts 
is  frequently  practiced.  I  recall  an  occasion,  several  years  ago, 
where  an  enraged  rattlesnake  escaped  from  an  experimenter,  strik- 
ing its  fangs  into  a  colored  assistant  standing  by.  Without  a 
moment's  hesitation,  the  gentleman  excised  the  part:  no  harm  ever 
came  of  the  matter.  Tiding  a  patient  over  the  depression  of  rattle- 
snake-poison by  the  stimulus   and    speciiic  effects  of  whisky  has 

let  him  be  awakened  every  hour  to  take  nourishment,  if  the  pulse  begins  to 
flag.  As  the  symptoms  of  shock  are  usually  the  result  of  serious  and  extended 
injury,  the  question  of  the  propriety  of  operating  for  the  relief  of  the  injured 
part  will  often  arise.  Unless  in  the  case  of  the  laceration  of  blood-vessels 
from  which  the  blood  oozes,  the  opinion  of  most  surgeons  is  adverse  to  the 
propriety  of  operating  until  reaction  is  fully  established ;  and  since  uncon- 
sciousness can  be  readily  induced  by  the  use  of  anesthetics,  the  supposed  ad- 
vantages derivable  from  amputating  a  limb  while  the  patient  was  unconscious 
of  the  injury  are  generally  regarded  as  evidence  of  a  want  of  judgment  on 
the  part  of  the  operator.  How  soon  after  a  reaction  an  amputation  should  be 
performed,  will  depend  on  circumstances,  and  be  again  alluded  to -when  speak- 
ing of  the  advantages  of  primary  over  secondary  amputations. 

"  Occasionally  it  happens  that,  after  reaction  is  established  and  traumatic 
fever  supervenes,  the  patient  becomes  delirious,  or  traumatic  delirium  or 
wandering,  without  fever,  is  met  with.  If  this  delirium  is  an  attendant  on 
the  febrile  condition,  sedatives,  cooling  applications,  and  the  judicious  use  of 
opiates,  with  antiphlogistic  remedies,  as  antimony,  arterial  sedatives,  and 
such  others  as  are  adapted  to  inflammatory  fever,  will  be  required  ;  in  other 
cases  opiates  are  mainly  sufficient.  Should  delirium  tremens  supervene,  the 
usual  treatment,  as  described  in  treatises  on  the  practice  of  medicine,  with 
great  attention  to  the  seat  of  injury,  will  be  requisite.  Among  high  livers  or 
in  the  intemperate,  a  comparatively  slight  injury  will  often  induce  an  attack 
of  delirium  tremens,  requiring  opiates  and  stimulants  to  counteract  it,  or,  if 
the  pulse  is  exceedingly  frequent  without  prostration,  the  administration  of 
large  doses  of  the  tincture  of  digitalis  or  vcratrum  viride.  In  delirium 
tremens  supervening  on  pistol' wounds,  in  many  of  our  volunteer  soldiers  in 
camp  for  the  first  time  and  deprived  of  their  habitual  drams,  I  have  seen 
marked  benefit  derived  from  the  administration  of  half  an  ounce  of  the  tinc- 
ture of  digitalis  every  four  hours  until  three  doses  are  taken,  this  apparently 
heroic  treatment  sometimes  inducing  a  perfect  cure  in  thirty-six  hours.  As 
the  dose  advised  is  very  large,  the  pulse  should  be  cautiously  watched  before 
it  is  repeated." 


WOUNDS  OF  MOUTH  AND  ASSOCIATE  PABTS.    607 

received  so  many  confirmations  as  to  have  become  a  matter  of 
common  knowledge.  In  my  own  practice  I  have  had  on  several 
occasions  to  excise  poison  wounds,  and  all  have  been  successful. 
Without  exception,  however,  the  wounds  excised  had  been  received 
through  some  intervening  substance,  and  such  substances  may  have 
prevented  the  introduction  of  any  poison. 

Healing  Wounds. — Primary  indications  met,  the  second  ques- 
tion is  the  healing  of  a  wound.  Every  wound  heals  by  granulation. 
The  difiFerence  between  a  healing  by  first  intention,  as  it  is  termed, 
and  a  healing  by  second  intention  is  only  a  difference  in  degree. 
An  incised  wound,  delicately  and  accurately  approximated,  heals 
with  so  little  new  inter-tissue  that  Mr.  Paget  mentions  cases  where 
no  line  of  difference  was  discernible  even  under  the  microscope.  A 
healing  by  second  intention,  so  called,  may  require  so  much  material 
to  fill  up  a  gap  that  the  new  or  cicatricial  tissue  is  observable  at  a 
great  distance,  as  is  frequently  witnessed  in  scars  from  burns.  An 
indication,  then,  of  the  utmost  importance  to  be  met  in  wounds 
about  the  face,  is  the  avoidance  of  a  necessity  for  new  tissue.  To 
accomplish  this,  every  wound  is  to  have  its  parts  as  nearly  and  as 
neatly  approximated  as  possible,  and  the  associated  vascularity 
controlled. 

How  wounds  are  best  approximated  is  a  matter  which  is  always 
eliciting  discussion.  The  common  methods  are  by  stitches,  plasters, 
and  compresses.  An  incised  wound,  of  limited  extent,  about  the 
cheek,  seldom  needs  more  than  that  a  strip  of  adhesive  plaster 
shall  be  thrown  across  it.  If  such  a  wound  occupies  the  position  of 
the  lips,  and  shall  have  made  a  complete  separation,  adhesive  plaster 
will  not,  perhaps,  be  found  sufficient  for  the  purpose.  To  insure  the 
least  scar,  a  stitch  may  be  used  to  approximate  the  free  edges,  and 
increased  support  given  by  placing'  two  lateral  compresses  at  the 
sides  of  the  wound,  approximating  these  with  a  turn  of  the  circular 
bandage ;  or  it  may  be  found  that,  after  the  stitch,  the  adhesive 
strips  will  answer  the  purpose.  Pins,  with  a  figure-of-8  turn  about 
them,  make  a  very  nice,  reliable,  and  accurate  adaptation,  and,  if  not 
kept  in  too  long,  leave  very  little  scar. 

A  mode  of  approximation,  which  will  be  found  very  satisfactory, 
consists  in  using  a  suture  of  silver  wire,  and  bringing  the  edges  of 
the  wound  together,  as  directed  in  cleft  palate.  An  objection,  how- 
ever, it  must  be  admitted,  to  all  pins  and  stitches,  lies  in  the  fact  of 
new  wounds  being  made, — an  irritation  being  begotten  by  the  pres- 
ence of  the  foreign  body,  which  is  very  apt  to  provoke  more  or  less 


608  ORAL  DISEASES  AND  SURGERY. 

suppuration,  thus  making  other  scars,  as  is  witnessed  so  frequently 
in  operations  performed  for  hare-lip  ;  therefore  it  may  be  set  forth  as 
the  best  practice,  that  any  means  which  breaks  the  flesh  should  be 
avoided,  if  any  other  may  be  made  to  answer.  Silver  or  lead  wire 
is  preferred  to  the  waxed  silk  only  from  the  fact  that  these  metallic 
agents  seem  to  irritate  less,  and  are,  therefore,  not  so  likely  to  make 
points  of  suppuration,  and  consequently  scars. 

When  pins  or  stitches  are  used,  they  are  to  be  left  in  place  only  so 
long  as  is  absolutely  necessary.  This  time  will,  of  course,  depend 
very  much  on  circumstances.  If  an  incised  wound  does  as  well  as 
it  may,  twenty  to  seventy  hours  will  usually  be  found  sufficient  for 
the  union,  while  instances  enough  exist  where,  in  this  time,  the  pro- 
cess of  repair  seems  scarcely  to  have  commenced.  A  very  good  way 
to  obtain  information  is  to  sponge  off  the  wound,  and  to  be  instructed 
by  the  line  of  approximation :  if  this  continues  to  show  its  incised 
nature,  the  pins  are  not  to  be  disturbed  ;  if,  on  the  contrary,  it  is  a 
fleshy  line  of  comparative  solidity,  the  pins  may  be  removed, — the 
parts  will  hold. 

The  withdrawal  of  a  pin  or  ligature  is  a  matter  demanding  delicacy 
of  manipulation.  It  is  frequently,  and  indeed  generally,  the  case, 
that  more  or  less  blood-rust  collects  upon  a  pin,  making  the  removal 
a  matter  of  such  difficulty  that,  unless  the  precaution  be  taken  to 
scrape  away  such  rust  before  making  the  attempt,  a  disturbance 
of  the  cicatrix  is  almost  inevitable.  In  the  withdrawal  of  a  pin, 
an  important  matter  is  the  rotation  of  it ;  such  rotation  facilitates 
the  removal  wonderfully.  Metallic  ligatures  are  generally  disturb- 
ing ;  the  proper  plan  to  take  them  away  is  to  cut  the  wire  at  the 
side  of  the  spot  or  knot  opposite  to  that  on  which  it  seems  desirable 
to  withdraw  it ;  the  end  is  then  to  be  carefully  straightened,  so  as 
to  place  it  on  a  line  with  the  part  in  the  wound ;  support  is  to  be 
given  the  cicatrix  by  a  finger  applied  on  either  side,  when,  with  a 
rotatory  movement,  the  wire  is  to  be  drawn  away.  In  the  use  of 
the  pin  and  figure-of-8,  a  very  excellent  plan  is,  on  the  removal  of 
the  pin,  to  allow  the  blood-matted  silk  to  remain  glued  to  the  wound  ; 
it  serves  to  hold  the  parts  together,  and  is  entirely  void  of  any 
offense  as  a  source  of  irritation. 

When  plasters  are  used,  it  is  a  necessity  to  have  all  hairs  shaved 
away  and  the  parts  perfectly  dry.  The  ordinary  adhesive  kept  on 
sale  by  every  druggist,  composed  of  resin  and  lead  plaster,  is  per- 
haps open  to  as  little  objection  as  any.  It  is  to  be  applied  in  strips 
of  convenient  length  and  breadth,  and  rendered  adhesive  by  holding, 


WOUNDS  OF  MOUTH  AND  ASSOCIATE  FARTS     609 

for  a  moment,  the  back  of  the  strip  over  a  vessel  of  hot  water.  There 
are  skins,  however,  which  this  plaster  irritates  and  inflames ;  when 
cases  of  the  kind  are  encountered,  it  is  well  to  employ  the  isinglass 
plaster.  An  objection  to  this  plaster  is  its  tendency  to  curl  and 
roll  up.     It  is  applied  by  moistening  the  glazed  surface  with  water. 

In  the  use  of  plasters,  it  is  a  good  rule  to  allow  a  space  between 
each  strip:  this  not  only  keeps  the  wound  exposed  to  observation, 
but  permits  of  easy  drainage.  The  only  exception  to  this  rule  is 
found  in  small  cuts  where  it  is  thought  desirable  to  use  collodion. 
This  mixture  of  gun-cotton  and  ether  is  applied  either  directly  over 
a  cut — first  nicely  approximating  the  edges,  and  holding  the  parts 
together  until  the  ether  has  evaporated — or  indirectly  through  the 
agency  of  saturated  slips  of  gauze  or  other  convenient  material. 

Tbe  removal  of  a  plaster  is  to  be  effected  by  drawing  the  strip 
from  either  side  toward  the  wound  ;  such  a  removal  being  accom- 
plished without  any  strain  upon  the  cicatrix,  the  line  of  union  being, 
of  course,  supported  by  the  thumb  and  forefinger  of  the  other  hand. 
If  a  wound  seems  to  be  doing  well  under  plaster,  there  need  be  no 
special  haste  in  its  removal.  It  is  usually  the  case,  however,  that 
such  a  dressing  will  not  continue  to  do  service  longer  than  two  or 
three  days.  In  simple  incised  injuries,  this  is  generally  all  that  is 
required,  but  in  lacerated  wounds,  dressings  are  demanded  an  in- 
definite length  of  time,  and  require  continued  renewal.  In  reapply- 
ing a  dressing  of  adhesive  strips,  a  good  plan  is  to  displace  and 
replace  one  at  a  time. 

Complicated  Wounds. — The  history  of  a  few  cases  may,  perhaps, 
best  serve  to  illustrate  practice  in  this  direction. 

Case  I. — Little  girl,  of  remarkably  perfect  temperament, — tem- 
peramentless,  it  might  be  said, — about  four  years  of  age,  brought 
into  the  office  with  quite  a  gash  in  the  lower  lip,  and  the  six  anterior 
teeth  knocked  directly  back;  considerable  hemorrhage. 

Treatment. — Checked  the  hemorrhage,  and  cleaned  the  parts  by 
the  free  use  of  cold  water  applied  through  the  syringe  ;  pushed  the 
teeth  back  into  their  unfractured  alveoli,  and  retained  them  in  place 
by  laying  a  delicate  roller  over  them,  fixing  it  beneath  the  chin.  A 
single  stitch  of  waxed  silk  was  placed  in  the  wound  of  the  lip.  The 
case  was  dismissed  for  the  day,  with  directions  to  keep  the  parts 
refrigerated  through  a  continuous  application  of  cold  water. 

Second  day.  Same  treatment  continued,  the  band  over  the  teeth 
being  replaced  by  a  fresh  one. 

Third  day.    Wound  in  the  lip  healed  sufficiently  to  remove  the 

39 


610  ORAL  DISEASES  AND  SURGERY. 

ligature.  Teeth  somewhat  tightened  ;  very  little  inflammation  ; 
continued  the  bandage,  but  left  off  the  application  of  the  water. 

Fourth  day.  Removed  the  bandage.  Teeth  very  sore,  but  doing 
well,  and  quite  fast. 

Eighth  day.  Patient  dismissed  ;  some  soreness  still  in  the  teeth, 
but  needing  only  time  to  bring  them  to  full  health. 

This  case  was  seen  three  months  after  the  accident ;  there  was  no 
discoloration  of  the  teeth,  and  not  the  slightest  evidence  that  any 
harm  had  been  done  them. 

Case  II. — Child  six  years  of  age.  Four  front  inferior  teeth 
knocked  loose  by  a  blow  from  a  ball ;  some  contusion  of  the  lip,  but 
no  break  in  the  continuity ;  very  little  bleeding. 

Treatvient. — Removed  the  injured  teeth  ;  absorption  having  pro- 
gressed to  a  considerable  extent,  applied  to  the  lips  dressing  of  cold 
water ;  case  well  enough  to  dismiss  next  day. 

Ca.se  III. — Little  boy,  five  years  of  age,  fell  upon  a  curbstone, 
fractuting  the  superior  alveolar  process.  Examination  revealed  six 
teeth  movable  in  mass,  the  fracture  extending  from  tuberosity  of 
right  side  to  canine  fossa  of  left.  The  accident  occurred  nine  hours 
bel'ore  recourse  to  treatment. 

Condition. — Child  feverish  and  restless;  pulse  much  excited; 
soft  parts  about  the  seat  of  fracture  considerably  swollen,  and  so 
tender  as  to  cause  the  little  patient  to  scream  when  the  parts  were 
touched. 

Treatment. — A  Seidlitz  powder;  hot  pediluvia;  the  mouth 
syringed  with  cold  water  ;  iced  lemonade  ad  lib.;  spts.  Mindereri, 
3'j,  j'g  S^-  acetate  of  morphia.  This  was  the  treatment  on  the  after- 
noon and  night  of  accident. 

Second  day.  Hot  pediluvia;  iced  lemonade,  made  of  crushed  ice; 
mustard  poultice  at  back  of  neck. 

Third  day.  Swelling  of  gums  very  much  abated.  Fed  the  child 
freely  with  spoon  food,  then  brought  the  fractured  part  to  its  place 
by  reducing  to  proper  articulation  with  lower  teeth,  and  retaining  in 
position  by  means  of  the  yard  strip  modification  of  the  Barton  band- 
age ;  a  fairly  comfortable  day  was  passed.  In  the  evening  the  band- 
age was  loosened,  the  child  again  fed,  the  bandage  tightened,  patient 
put  to  bed  ;  a  comfortable  night  was  passed. 

Fourth  day.  Doing  very  well.  On  loosening  the  bandage  there 
was  very  little  tendency  in  the  fractured  part  to  move  of  itself;  child 
fed  with  soup  food ;  mouth  well  syringed  with  cold  water ;  bandage 
reapplied.     Patient  played  about  the  room  most  of  the  day,  taking 


WOUNDS  OF  MOUTH  AND    ASSOCIATE  PARTS.     611 

lemonade  and  rice-gruel  very  frequently,  by  placing  the  fluid  within 
the  lips  and  sucking  it  between  the  teeth. 

From  fifth  to  tenth  day  did  little  more  than  continue  the  treatment 
of  the  fourth. 

Eleventh  day.  Removed  the  bandage.  Fracture  fairly  solid  ;  able 
to  hold  of  itself;  liquid  food  continued;  no  other  treatment. 

Fifteenth  day.  Patient  began  to  eat  solid  food  ;  passing  on,  with- 
out further  treatment,  to  a  good  cure. 

Case  IV. — Little  girl,  three  years  of  age,  markedly  scrofulous; 
lip  cut  through  ;  fracture  of  process  of  central,  lateral  incisor,  and 
cuspid  teeth  of  left  side  inferior  maxilla ;  cutting  edges  of  teeth 
thrown  backward. 

Treatment. — The  wound  in  the  lip  being  quite  extensive,  a  hare- 
lip pin  was  inserted,  and  the  parts  pushed  together  and  held  with  a 
figure-of-8.  The  fractured  process  was  restored  to  position,  and 
retained  by  tying  the  one  end  of  a  strand  of  waxed  floss  silk  around 
the  last  molar  tooth  of  the  injured  side,  bringing  it  forward,  passing 
it  between  the  first  molar  and  cuspis  of  the  fractured  part,  back  of 
the  three  teeth  of  the  broken  process,  then  out  between  the  central 
incisors,  and  back  to  the  first  molar,  where  it  was  tied.  This  liga- 
ture supported  the  part  in  its  place  very  well.  The  ferrated  elixir 
of  bark,  in  doses  of  twenty-five  drops,  directed  three  times  a  day. 

Second  day.  Wound  in  the  lip  doing  tolerably  well ;  seat  of  frac- 
ture looking  puffy  and  asthenic.  Yery  weak  solution  of  compound 
tincture  of  capsicum  ordered  to  be  thrown,  ter  die,  over  the  part. 

Third  day.  Looking  worse ;  ligatures  cutting  into  the  gums ; 
patient  refusing  solid  or  soft  food  ;  took  away  the  ligature  ;  tempted 
the  appetite  with  ice-cream  and  jellies ;  scarified  the  puffy  gum. 

Fourth  day.  Matter  oozing  from  about  seat  of  fracture  ;  etherized 
the  child  ;  dissected  down  to  the  fractured  piece,  and  removed  it. 

Sixth  day.  Very  much  improved;  wound  healing  fairly;  con- 
tinued to  syringe  with  the  dilute  capsicum  comp. 

Eighth  day.  Case  well  enough  to  be  dismissed.  The  pin  in  the  lip 
had  been  removed  on  the  third  day.  The  wound  gaped  some  little  ; 
but  the  removal  was  a  necessity,  on  account  of  irritation  produced 
by  its  presence  ;  support  was  given  by  an  adhesive  strip,  after  the 
taking  away  of  the  pin,  and  the  part  stimulated  with  capsicum, 
under  which  it  healed  very  rapidly. 

Case  V. — M.  L.,  an  iceman,  aged  perhaps  thirty-five,  brought  into 
the  office  immediately  after  having  been  kicked  on  the  mouth  by  a 
vicious  mule.     Patient  very  pale  and  faint.     Examination  revealed 


612  ORAL  DISEASES  AND  SURGERY. 

comminuted  fractures  of  the  alveolar  process  of  both  jaws,  with  the 
teeth  knocked  into  every  position. 

Treatment. — First,  stimulation  with  a  little  brandy.  The  patient 
revived.  Incisions  on  either  side  of  the  teeth  were  made  down  to 
the  bone,  and  some  eight  pieces  removed,  with  the  teeth  associated. 
No  hemorrhage  of  consequence  attended  the  operation,  and  in  the 
course  of  three  or  four  days  the  man  was  going  about  his  business, 
— no  treatment,  outside  of  the  free  use  of  cold  water,  having  been 
indicated  or  employed. 

Case  VI. — C.  H.,  struck  over  the  angle  of  the  jaw  by  a  minie- 
ball,  which  plowed  across  the  face,  completely  dividing  the  cheek, 
and  grooving  the  right  nasal  ala.  A  first  treatment  employed  on 
the  field,  where  the  injury  was  received,  consisted  in  associating  the 
severed  parts  with  a  series  of  interrupted  sutures,  and  the  application 
of  a  poorly  adapted  bandage.  In  this  condition  the  patient  was  sent 
several  days'  journey,  to  a  hospital  in  which  I  happened  at  the  time 
to  be  employed.  My  first  observation  of  the  case  exhibited  an  im- 
mense wound,  stitches  all  torn  out ;  superior  maxillary  bone  exposed, 
with  groove  cut  into  it ;  suppuration  most  profuse ;  patient  ex- 
hausted, irritable,  and  feverish. 

Treatment. — The  weather  being  oppressively  hot,  a  large  basin  of 
water  was  brought,  in  which  the  head  and  face  were  thoroughly,  yet 
tenderly,  washed.  The  matted  hair  was  combed  out  and  arranged. 
This  refreshed  him  very  much.  Examination  of  the  wound  was 
commenced.  On  the  groove  in  the  bone  was  found  no  splinter,  nor 
other  indication  adverse  to  the  direct  and  immediate  overlying  of 
it  by  the  soft  parts.  Attention  to  the  line  of  wound  in  the  soft  part 
exhibited  that  the  slough,  which  must  necessarily  have  ensued  from 
the  passage  of  the  ball,  had  been  completed,  and  that  a  process  of 
repair  was  attempting  to  inaugurate  itself.  Indications  thus  being 
rendered  very  plain,  the  whole  of  the  cut  and  suppurating  surface 
was  slightly  stimulated  by  an  application  of  dilute  tincture  of  iodine, 
and  then  carefully  moulded  into  place  and  approximated.  The  main- 
tenance of  this  apposition  was  accomplished  by  fitting  a  compress  to 
the  cheek,  and  also  below  the  wound,  and  with  a  bandage,  carefully 
lifting  and  supporting  it;  no  stitches,  pins,  or  plasters  being  em- 
ployed. The  success  was  perfect,  the  whole  line  of  the  wound  being 
exposed,  permitting  the  fullest  and  most  frequent  examination.  In 
ten  weeks  the  parts  had  united  so  firmly  as  to  allow  of  the  removal 
of  the  compress  and  bandage.  The  only  medication  employed  con- 
sisted in  the  administration  of  an  occasional  Seidlitz  powder,  and  a 


WOUNDS  OF  MOUTH  AND   ASSOCIATE   PARTS.     613 

daily  glass  of  porter,  with  repeated  applications  to  the  wound  of  the 
dilute  iodine,  one  part  of  the  officinal  tincture  to  four  parts  water. 

Case  VII. — Little  girl  fell  over  the  shafts  of  a  wagon,  cutting,  in 
some  unappreciated  way,  her  tongue  directly  in  twain,  for  the  dis- 
tance of  an  inch  down  the  middle.  Hemorrhage  was  very  profuse, 
requiring  the  ligature  of  a  vessel.  This  wound  was  united  by  two 
stitches  of  the  interrupted  suture  passed  deep  in  the  substance  of 
the  organ  ;  cold  water  directed  to  be  held  in  the  mouth  quite  continu- 
ously, for  the  first  day  ;  patient  fed  on  ice-cream  and  jelly.  Third  day, 
■  stitches  removed,  union  complete,  ligature  loosened,  and  was  pulled 
away  on  the  seventh  day. 

Case  VIII. — Brigadier-General  D.,  standing  upon  an  outlook,  was 
struck  by  a  sharpshooter,  the  ball  passing  through  the  right  ramus 
of  the  lower  jaw,  shattering  the  bone,  passing  forward  across  and 
through  the  tongue,  emerging  from  and  splintering  the  body  of  the 
bone  on  the  left  side.  The  treatment  pursued  upon  the  field  had 
been  to  check  an  alarming  hemorrhage  from  the  region  of  entrance 
of  the  ball,  by  stuffing  the  wound  with  charpie  saturated  with 
Monsel's  solution  of  iron,  throwing  a  bandage  over  it,  and  hurrying 
the  patient  to  the  hospital. 

Condition  on  enti^ayice. — Patient  arrived,  and  was  put  under  my 
care  about  eleven  o'clock  at  night;  complained,  by  writing  on  a  slate, 
of  great  thirst,  with  entire  inability  to  swallow,  and  of  the  painful 
eflfort  it  required  to  breathe ;  had  not  been  able  to  drink  since  the 
accident,  which  happened  two  days  before. 

Treatment. — Examination  revealed  marked  displacement  of  the 
middle  piece  of  the  fractured  bone.  This,  with  the  tongue  being 
pulled  backward  by  the  hyoid  attachment  of  the  genio-hyoglossal 
muscles,  sufficed  to  explain  part  of  the  difficulty  in  respiration  and 
deglutition.  The  tongue  itself,  however,  was  much  swollen,  and 
had  a  ball  wound  through  its  base.  Two  primary  indications  thus 
presented :  to  keep  the  body  of  the  bone  and  tongue  in  position,  and 
to  reduce  the  swelling  in  the  tongue.  The  external  wounds  were 
for  secondary  consideration  :  the  patient  had  to  breathe  and  had  to 
be  nourished.  The  mouth  was  first  well  syringed  with  cold  water, 
which  was  found  most  refreshing ;  the  bone  was  then  brought 
forward,  the  inferior  teeth  in  front  of  the  superior ;  the  jaws  were 
closed,  and  held  together  by  a  delicate  bandage,  the  middle  fragment 
being  thus  retained  even  in  front  of  its  natural  position,  and  pulling 
the  tongue  forward  with  it.  This  accomplished,  the  patient  was 
propped  up  in  an  arm-chair,  and  his  feet  immersed  in  hot  water,  the 


614  ORAL  DISEASES  AND  SURGERY. 

application  being  continued  until  every  vein  and  capillary  was  en- 
gorged. A  local  abstraction  of  blood  was  not  thought  desirable,  as 
he  had  already  lost  as  much  as  he  could  well  spare.  The  result 
of  such  a  primary  treatment  was,  that  in  half  an  hour  the  patient 
was  able  to  swallow  spoonfuls  of  lemonade.  This  drink,  cold  as  it 
could  be  made,  was  continued  during  most  of  the  night,  serving  by 
its  refreshment  to  give  much  comfort,  and  by  its  refrigeration  to 
abate  the  vascular  excitement.  About  four  o'clock  in  the  morning 
the  patient  fell  into  a  disturbed  sleep,  which  continued  until  eight. 
At  nine  o'clock  the  tongue  was  examined  by  separating  the  lips  and 
looking  at  it  through  spaces  which  existed  between  the  teeth  ;  the 
swelling  and  turgidity  had  very  much  diminished.  The  feet  were 
again  placed  in  hot  water,  and  the  blood  held  in  the  parts  until  a 
sense  of  faintness  was  experienced.  This  gave  increased  relief  The 
patient  thus  being  over  the  immediate  danger,  attention  was  directed 
to  the  state  of  the  external  injuries,  and  the  line  of  passage  of  the  ball. 

The  wound  at  the  external  angle  of  the  jaw  was  found  to  occupy 
quite  a  space  in  the  parotid  fossa,  the  ball  having  evidently  been 
received  as  the  general  had  turned  his  head  to  address  some  one 
behind  him.  It  was  stuffed  with  charpie,  looking  now  a  black  and 
blood-infiltrated  mass,  and  which  evidently  had  been  thrust  hard  and 
solidly  into  the  wound,  and  now  had  swelled  to  double  its  former  size, 
displacing  the  parts  to  a  very  marked  extent.  This  plug  being  found 
firmly  fixed,  it  was  left  to  be  removed  or  not,  as  circumstances  should 
seem  to  direct,  at  a  future  time.  The  wound  of  exit  was  larger  than 
might  have  been  expected,  spiculae  of  bone  having  considerably  torn 
the  parts ;  from  it  were  removed  several  small  splinters.  The  probe, 
passed  into  this  opening,  revealed  the  line  of  the  wound  running 
through  the  base  of  the  tongue  obliquely  across  the  mouth.  The 
treatment  consisted  in  the  free  use  of  permanganate  of  potash  and 
water.     The  patient  passed  the  day  in  a  fair  degree  of  comfort. 

A  sudden  secondary  hemorrhage  being  the  next  thing  to  fear,  it 
was  determined  on  the  third  day  to  remove  the  plug ;  this  was  ac- 
complished only  after  a  full  hour  of  labor,  the  charpie  having  wedged 
itself  into  every  imaginable  space,  the  removal  being  effected  by  the 
very  free  use  of  milk-warm  water  and  the  most  gentle  of  traction 
with  the. forceps  and  scalpel  handle.  The  removal  was  attended  with 
considerable  pain,  but  without  the  loss  of  a  single  drop  of  blood. 
The  relief  from  the  sense  of  pressure  afforded  was  so  very  great  as 
to  change  the  whole  appearance  of  the  patient,  he  now  breathing 
and  taking  his  beef-essence  with  the  greatest  freedom.    The  appear- 


WOUNDS   OF  MOUTH  AND  ASSOCIATE  PARTS.     615 

ance  of  the  wound  was  really  very  promising,  attempts  at  granula- 
tion being  quite  evident,  while  nothing  especially  threatening  was 
to  be  observed.  The  day  after  this  dressing,  the  patient,  in  opposi- 
tion to  all  advice  or  commands,  insisted  on  being  passed  to  his  family 
in  Washington.  All  the  dangers  of  secondary  hemorrhage  were 
exposed  and  explained  to  him,  but  he  seemed  to  be  possessed  of  the 
single  idea  of  getting  to  his  home.  At  five  o'clock  in  the  afternoon 
he  was  driven  to  the  steamer  plying  between  Fortress  Monroe  and 
Baltimore,  continued  in  charge  of  a  surgeon  who  had  been  sent  with 
him  from  the  field.  At  midnight,  while  on  the  Chesapeake,  the  most 
profuse  secondary  hemorrhage  came  on,  which  was  controlled,  as 
best  it  might  be,  by  masses  of  ice  held  continuously  to  the  wound. 
The  patient  died  during  the  next  day  at  a  hospital  on  the  wharf  in 
Baltimore,  under  what  exact  circumstances  I  could  not  learn  ;  most 
likely,  however,  from  exhaustion. 

Case  IX. — J.  B.,  middle-aged  man,  gash,  from  a  blow,  lacerating 
the  cheek,  opening  the  duct  of  Steno. 

Treatment. — With  a  heavy-eyed  needle,  carried  a  loop  from  the 
bottom  of  the  wound  to  the  inside  of  the  cheek:  the  silk,  which 
was  very  loose,  conducted  the  saliva  into  the  mouth.  Brought  the 
external  wound  together  by  strips  of  resin  plaster ;  no  other  treat- 
ment required,  save  an  occasional  dressing.  In  a  week  the  loop 
had  sloughed  through  into  the  mouth,  preserving  completely  the 
track  for  the  secretion,  and  the  process  of  granulation  had  ad- 
vanced almost  to  the  stage  of  cure  in  the  external  wound.  No  after- 
trouble. 

Case  X. — C.  A.,  young  gentleman,  twenty  years  of  age,  deep 
punctured  cut  in  the  floor  of  the  mouth  just  to  left  of  middle  line, 
made  by  the  slipping  of  an  elevator  in  the  attempt  to  remove  root 
of  upper  canine  tooth.  No  hemorrhage,  or  immediate  ba,d  sign  of  any 
kind;  patient  very  much  frightened.  Accident  had  occurred  two 
days  before  my  seeing  the  case  ;  part  very  sore  and  tender;  inflam- 
mation limited. 

Treatment. — Directed  arnica-water  for  relief  of  the  soreness  ; 
nothing  else  indicated  or  required  ;  the  wound  healing  rapidly  and 
kindly. 

Case  XI. — Cut  received  by  young  lady,  exposing  and  incising 
mylo-hyoid  artery  of  left  side  in  the  groove;  hemorrhage  very  great 
and  persistent. 

Treatment. — Upright  position;  tinct.  Erigeron  as  directed;  strong 
alum  solution  held  to  the  part  on  tufts  of  cotton,  afterward  thrown 


616  ORAL  DISEASES  AND   SURGERY. 

with  the  syringe ;  ice  to  the  part,  etc.  No  result  on  the  bleeding. 
The  patient  becoming  affected  from  loss  of  blood,  enlarged  the 
wound,  picked  out  the  vessel  with  the  Liston  forceps,  and  tied  it. 
This,  of  course,  controlled  the  hemorrhage.     Patient  recovered. 

Case  XII. — Mr.  C.  Performed  operation  on  the  cheek  for  a  pecu- 
liar erectile  growth ;  cut  well  into  the  sub-tissue,  making  quite  a 
deep  wound,  just  as  if  the  part  had  been  scooped  out. 

Treatment. — Cold-water  dressing;  waiting  on  nature  to  fill  up 
wound  with  granulations;  nothing  else  required,  nothing  done;  the 
case  progressed  to  a  satisfactory  cure,  excepting  a  raised  scar. 

Case  XIII. — Young  man,  shot  through  the  cheek ;  the  mouth 
being,  at  the  time,  fortunately  open,  the  ball  passed  out,  doing  no 
further  damage;  no  hemorrhage. 

Treatment. — Applied  cloths  wrung  out  of  cold  water,  for  the  pur- 
pose of  controlling  vascular  reaction  ;  nothing  else  done  ;  wound 
suppurated  until  the  compressed  and  devitalized  tissues  were 
sloughed  ;  then  kindly  granulated,  the  patient  being  entirely  well 
in  a  month. 

Case  XIV. — Patient,  young  lady.  In  an  attempt  to  extract  the 
first  molar  tooth  of  right  upper  jaw,  a  flap  of  gum  had  been  torn, 
extending  around  the  mouth  to  the  left  second  bicuspid ;  this  flap 
had  been  hanging  loose  some  three  hours  before  the  patient  pre- 
sented herself 

Treatment. — Cut  it  off,  and  depended  on  granulations  from  the 
wounded  surface  for  the  filling  up ;  patient  comfortable  next 
day ;  entirely  well  in  a  week ;  no  other  treatment  of  any  kind  re- 
quired. 

Case  XV. — Boy,  twelve  years  of  age  ;  playing  with  powder  con- 
tained in  a  bottle,  it  unfortunately  exploded,  throwing  the  glass  and 
powder  into  his  face.  When  first  seen,  an  hour  after  the  accident, 
the  patient  was  in  the  greatest  distress;  the  eyes  were  completely 
closed,  lashes  entirely  destroyed,  hair  singed,  face  raw  and  bleeding, 
pulse  rapid,  aud  very  irritable. 

Treatment. — First,  Seidlitz  powder,  with  half-grain  of  opium ; 
second,  removal  of  such  pieces  of  glass  as  could  be  readily  picked 
away  with  the  forceps;  third,  cold-water  dressing.  In  an  hour 
the  patient  was  fairly  comfortable;  at  the  end  of  which  time  a  second 
half-grain  of  opium  was  administered. 

Second  day.  Face  very  sore,  but  no  burning  pain  ;  picked  away 
several  small  pieces  of  glass  and  a  number  of  powder-grains.  Con- 
tinued cold-water  dressinar. 


WOUNDS  OF  MOUTH  AND  ASSOCIATE  PARTS.     617 

Third  day.  Reactive  inflammation  evidently  aborted ;  water 
dressings  dispensed  with;  used  in  place 

R. — Olei  lini, 

Aquae  calcis,  aa  q.  s. 

With  this  the  surface  was  protected  from  the  atmosphere  until  it 
cicatrized, — a  period  of  two  weeks.  During  the  time  of  cure  some 
little  attention  was  given  to  the  diet,  the  patient  for  the  6rst  day 
craving  principally  ice-cream,  which  answered  very  well,  and  served 
to  allay  a  slight  tendency  to  irritative  fever  which  existed;  the 
latter  four  days  of  the  first  week  stimulating  articles  of  food  were 
interdicted  ;   after  this  he  ate  what  he  best  liked. 

Case  XVI. — Patient,  young  gentleman.  Struck,  while  on  a 
gunning  excursion,  by  a  buckshot,  which  passed  through  the  lower 
lip,  burying  itself  in  the  bone.  Patient  not  seen  until  the  next  day; 
lip  too  much  swollen  to  permit  of  examination. 

Treatment. — Cold-water  dressing  to  the  lip.  Mag.  sulph.  ^ss 
internally. 

Third  day.  No  diminution  in  swelling;  slight  erysipelatous 
blush;  brushed  the  parts  with  the  following  combination: 

B. — Tineturae  ferri  chloridi,  J'j ; 
Quinije  sulphatis,  gr.  xxx  ; 
Tineturae  cinchonae,  5j.     M. 

In  one  hour  the  blush  disappeared. 

Fourth  day.  Inflammation,  with  the  swelling,  disappearing  very 
rapidly. 

Sixth  day.  Probed  the  wound ;  discovered  the  shot  lying  near  the 
root  of  the  first  bicuspid  tooth ;  dissected  away  the  gum  from  the 
inside,  and  with  a  very  small  curved  gouge  picked  the  lead  away. 

Seventh  day.  Inflammation  back  again,  confined,  however,  rather 
to  the  inside  of  the  mouth;  reapplied  the  cold-water  dressing,  and 
directed  a  Seidlitz  powder. 

Eighth  day.  Better  ;  inflammation  rapidly  yielding  ;  a  little  pus 
escaping  from  the  shot  track  in  the  bone. 

Tenth  to  thirteenth  day.  Track  of  wound  in  the  bone  suppu- 
rating considerably  ;  tinct.  iodine  injected. 

Fourteenth  day.   Discharge  diminishing;  iodine  still  continued. 

■  Sixteenth  day .  Discharge  entirely  ceased  ;  patient  dismissed. 

Case  XVII. — Patrick  T.,  laborer.     While  engaged  in  blasting 


618  ORAL  DISEASES  AND  SUBGERY. 

rocks,  the  patient  was  struck  with  great  force,  just  below  the  orbit, 
by  a  flying  fragment,  lacerating,  in  a  frightful  manner,  the  soft  parts 
of  the  face,  breaking  and  knocking  into  the  naris  the  left  nasal  bone, 
and  severely  concussing  the  maxillary.  No  hemorrhage ;  heavy 
shock. 

Treatment. — The  patient  being  a  strong,  plethoric  man,  reaction 
was  allowed  to  establish  itself,  which  it  did  completely  only  after 
the  lapse  of  several  hours.  Cold-water  dressings  were,  however, 
at  once  applied  to  the  parts,  every  deduction  being  in  favor  of  the 
inference  of  sevei'e  inflammation.  The  accident  occurred  in  the 
morning.  At  seven  in  the  evening,  a  pine  stick,  whittled,  to  make 
its  introduction  easy,  was  coated  over  the  end  by  dipping  it  in 
melted  wax,  and  with  this,  insinuated  into  the  nostril  beneath 
the  depressed  nasal  bone,  it  was  thrust  out  into  place,  position 
being  maintained  by  a  tuft  of  wax-coated  cotton,  having  attached 
to  it  a  string  for  its  withdrawal,  being  pushed  up  beneath  the 
fracture. 

.  Examination  of  the  injured  face  and  maxillary  bone  revealed  con- 
tusion and  injury  to  such  an  extent  as  to  make  it  evident  that  the 
process  of  cure  must  be  that  of  exfoliation,  sloughing,  and  repair 
by  granulation  ;  the  only  treatment  was  then  the  expectant,  and 
this  was  met  by  a  simple  water  dressing. 

Second  day.  Most  decided  reaction.  Mag.  sulph.  ^ss  adminis- 
tered in  half  a  glass  of  water;  water  dressing,  medicated  with  lead 
and  laudanum. 

R. — Plumbi  acetatis,  5'j  ; 
Tincturse  opii,  ^ij ; 
Aquae,  ^xxx.     M. 

Cloths  wet  with  this  lotion  kept  constantly  upon  the  cheek. 

TJiird  day.  Inflammation  abating,  but  patient  complaining  of 
feeling  hot  and  generally  miserable.  Lemonade  ordered  as  a  febri- 
fuge, to  be  made  by  expressing  the  juice  of  an  ordinary  lemon  into 
a  goblet,  sweetening,  and  filling  up  the  glass  with  ice  broken  into  a 
coarse  powder.     To  be  allowed  ad  libitum. 

Fifth  day.  Wound  suppurating;  fever  all  gone;  dressing  changed 
to  simple  water ;  waxed  cotton  changed  in  nostril, — the  replacement 
giving  much  pain. 

From  fifth  to  tenth  day.  Water  dressing  continued  ;  portion  of 
external  plate  of  the  bone  apparently  dying ;  periosteum  evidently 
destroyed. 


WOUNDS   OF  MOUTH  AND  ASSOCIATE  PARTS.     619 

Eleventh  day.  Stimulation  commenced  ;  parts  wet  three  or  four 
times  a  clay  with  the  following: 

R. — Aluminis  pulveris,  5"j  J 

Tincturae  capsici  compositae,  ^ss; 
Aquae,  5xvj.     M. 

Fifteenth  day.  Granulations  being  thrown  out  from  around  the 
edges  of  the  wound ;  parts  brought  as  closely  together  as  possible, 
and  retained  with  adhesive  strips  ;  nasal  fractux'e  doing  very  well. 

Twenty-fiflh  day.  Wound  of  face  entirely  healed,  with  the  ex- 
ception of  a  small  place  in  the  centre,  which,  when  examined  with 
the  probe,  discovered  a  sinus  leading  to  diseased  bone. 

Thirty-fourth  day.  Piece  of  bone  presenting  at  the  sinus ;  en- 
larged the  opening,  and  withdrew  a  sequestrum  rather  larger  than  an 
ordinary  finger-nail.  Examination  with  the  probe,  after  the  removal, 
gave  the  fleshy  feel  indicative  of  repair.  Case  dismissed  on  the 
thirty-sixth  day. 

Case  XVIII. — Young  man,  struck  on  the  side  of  the  face,  in  a 
street-brawl,  with  a  slung-shot;  face  severely  cut  and  contused; 
outer  boundary  of  the  antrum  driven  backward  into  the  cavity,  not 
fractured  apparently,  but  simply  bent  inward. 

Treatment. — Cold-water  dressing, — no  other  application  for  the 
first  three  days.  After  this,  the  patient  being  compelled  to  go  out 
to  his  work,  adhesive  strips  were  employed;  repair  progressed 
rapidly,  without  a  single  adverse  manifestation.  The  depressed 
plate  of  the  sinus  gave  no  trouble,  soon  accommodating  itself  to  its 
new  position  ;  all  sense  of  soreness  leaving  it  by  the  end  of  the 
second  week.     External  wound  cicatrized  in  twenty  days. 

Case  XIX. — A  young  man  slipped  while  standing  on  a  stall  in  a 
market-house  ;  falling  forward  and  downward  upon  one  of  the  hooks, 
it  entered  his  mouth,  breaking  off  three  of  his  upper  teeth,  perfo- 
rated his  hard  palate,  and  passed  by  its  point  into  the  right  nostril. 

Treatment. — Seen  first  one  hour  after  the  accident.  Pain  in  the 
broken  teeth  unbearably  severe.  Examination  discovered  the  en- 
gorged pulps  entirely  uncapped  and  bulging  from  their  cavities. 
The  probe  introduced  through  the  wound  in  the  palate  passed  readily 
into  the  nares,  giving  little  or  no  pain.  No  fracture  of  the  bone, 
save  a  few  trifling  spicule  about  the  circumference  of  the  puncture. 
The  roots  of  the  broken  teeth  were  at  once  extracted,  and  the  case, 
for  the  time,  left  to  nature. 


620  ORAL  DISEASES  AND  SURGERY. 

Second  day.  No  necessity  for  any  interference ;  some  soreness, 
but  no  actual  pain. 

Tfiird  day.     Nothing  required  to  be  done. 

Fourth  day.  Three  trifling  pieces  of  bone  discharged  into  the 
mouth. 

Seventh  day.     Wound  granulating  very  satisfactorily. 

Fifteenth  day.  Nature  unable,  evidently,  to  quite  fill  up  the  open- 
ing; assisted  by  scarifying  the  circumference  of  the  wound,  and 
touching  with  tincture  of  iodine. 

Seventeenth,  tiventieth,  and  twenty-second  days.  Scarified,  and 
touched  with  iodine. 

Twenty-fourth  day.    Opening  completely  closed.    Case  dismissed. 

Case  XX. — Gentleman.  While  striking  the  iron  handle  of  a  chisel 
in  the  act  of  opening  a  box,  a  small  piece  flew  off  from  the  hammer, 
burying  itself  in  the  malar  process  of  superior  maxillary  bone. 

Treatment. — With  probe,  searched  in  the  wound  for  the  foreign 
body;  found  it  in  position  as  described,  with  very  oblique  track 
through  soft  parts.  Introduced  a  sharp  steel  instrument,  and,  after 
some  trouble,  succeeded  in  working  the  pjece  loose;  could  not,  how- 
ever, get  hold  of  it  with  forceps  without  such  manipulation  as  would 
evidently  enough  contuse  the  parts.  Introduced  a  director  down  to 
the  body,  and  cut  to  it;  removed  it  in  this  way  without  effort. 
Wound  closed  with  two  delicate  sutures,  and  the  cold-water  dress- 
ing applied  ;  in  three  or  four  days  the  parts  were  entirely  well,  with- 
out the  slightest  suppuration  having  occurred, — no  noticeable  scar 
being  left. 

Case  XXI. — A  little  boy,  Harry  H.,  while  playing  with  a  wooden 
paddle  which  had  been  made  for  use  in  rendering  lard,  slipped, 
while  having  one  end  of  it  in  the  mouth,  the  weight  of  his  body 
carrying  the  stick  through  the  soft  palate,  making  a  complete 
separation  between  the  veil  and  hard  parts.  This  patient  was  first 
seen  three  days  after  the  injury.  No  inflammation  of  consequence 
existing. 

Treatment. — Etherizing  the  patient,  the  parts  were  stitched  to- 
gether with  interrupted  sutures  of  silver  wire,  the  approximation 
being  maintained  by  perforated  shots  clamped  over  the  wire.  Only 
a  very  limited  union,  however,  was  secured,  the  two  most  important 
stitches  sloughing  out.  Oq  the  fourth  day  from  the  introduction  of 
the  first  stitches,  those  which  had  been  lost  were  replaced,  which 
last,  by  the  eighth  day,  also  sloughed  out,  yielding  no  increase  in 
extent  of  the  union,  but  happily  being  associated  with  such  extent 


WOUNDS   OF  MOUTH  AND   ASSOCIATE  PARTS.     621 

of  granular  face  to  the  wound  that,  when  the  veil  was  pressed  up- 
ward, it  met  the  part  from  which  it  had  been  torn.  An  impression 
of  the  mouth  was  now  taken  in  very  soft  wax.  From  this  a  nTodel 
was  secured,  to  which  model  was  struck  a  silver  plate.  This  plate 
enveloped  the  back  teeth  of  the  upper  jaw,  but  was  cut  to  fit  the 
palatine  faces  of  the  anterior.  Impressions  were  next  taken  of  the 
inferior  teeth,  and  caps  made  to  fit  the  molars.  Putting  next  the 
plate  and  caps  in  place,  they  were  attached  by  means  of  wax,  and 
the  apparatus  thus  associated  lifted  carefully  from  the  mouth,  the 
piece  being  completed  by  soldering  the  parts  together.  Thus  pre- 
pared, the  apparatus  was  put  in  the  mouth,  and  the  two  jaws  held 
in  place  by  means  of  the  Garretson  bandage.  In  two  weeks  union 
was  sufficiently  firm  to  permit  the  removal  of  the  splint. 

Case  XXII. — Stout  Irish  lad,  twelve  years  of  age,  shot  in  the 
face  by  a  playmate.  In  this  case  the  pistol  was  in  the  hands  of  a 
smaller  boy,  the  muzzle  being  directed  obliquely  upward.  The  ball, 
which  was  a  good-sized  minie,  struck  the  centre  of  the  nose,  and, 
as  it  passed  upward  on  the  line  of  its  projection,  was  deflected  at  an 
angle  of  about  eighty  degrees,  by  an  influence  exerted  by  the  nasal 
bones,  against  which  it  struck.  This  boy  was  first  seen  on  the 
second  day  after  the  accident.  No  inflammation,  no  evidence  of 
shock,  indeed,  no  anything  that  would  lead  to  the  inference  of  an 
accident  of  gravity ;  even  the  wound  of  entrance  was  scabbed  over, 
and  looked  like  any  insignificant  sore. 

Treatment. — Breaking  away  the  scab,  search  was  made  for  the 
course  of  the  ball  by  means  of  the  ordinary  silver  probe.  As  the 
instrument  reached  the  nasal  bones,  the  condition  of  reflection  was 
recognized.  Examining  next  the  mouth  of  the  patient,  a  solid  pro- 
jection was  observed  at  the  line  of  union  of  the  palatine  plates  of 
the  maxilla  and  palate  bones.  Inferring  this  to  be  the  ball,  an  in- 
cision was  made  through  the  soft  parts ;  this  exposed,  however,  not 
the  ball,  but  a  fractured  portion  of  bone.  Eemoving  this,  the  ball, 
much  flattened,  was  found  immediately  above  it,  being  wedged  in 
the  site  from  which  it  had  forced  the  bone.  The  boy  seemed  to  re- 
quire no  treatment,  and  therefore  received  none.  In  no  way  had  he 
a  bad  symptom. 

Case  XXIII. — Michael  M.,  car-driver.  Separation  from  its  max- 
illary attachment  of  left  nasal  bone.  Deformity  very  marked;  the 
whole  nose  looking  as  if  it  had  been  thrust  upon  one  side  of  the  face. 

Treatment. — The  parts  being  very  much  inflamed,  application  of 
the  lotion  of  lead-water  and  laudanum  was  ordered,  and  continued 


622  ORAL  DISEASES  AND  SURGERY. 

until  the  condition  was  fully  combated  ;  two  days  being  required 
to  secure  such  a  desired  result.  Using  now  the  handle  of  an  ordi- 
nary scalpel,  the  displaced  bone  was  lifted  into  position,  and  was 
retained  by  making  a  flattened  roll  of  the  common  adhesive  plaster, 
— the  unspread  side  out;  this,  being  dipped  in  olive  oil,  was  directed 
into  place,  and  retained  for  a  week  by  a  ligature,  which  kept  it  welL 
in  position  by  passing  over  each  ear.  At  the  end  of  this  period  the 
roll  was  withdrawn  and  the  parts  left  to  nature.  A  perfect  cure 
resulted. 

Case  XXIV. — From  Langenbeck.  Head  of  patient  was  caught 
between  a  locomotive  and  its  tender.  The  eyelids  were  torn  away 
from  the  orbit,  and  a  deep  wound  ran  dow^u  from  the  inner  canthus 
to  the  upper  lip.  A  probe  could  be  passed  into  the  antrum:  not  a 
trace  of  the  eyeball  could  be  found;  while  in  the  orbit  was  a  bluish- 
black  pulsating  mass.  The  nasal  bones  comminuted.  Patient  con- 
scious, but  sleepy;  pulse  slow;  violent  pain  on  right  side  of  head. 
A  week  afterward,'  as  head  symptoms  disappeared,  and  the  extrava- 
sated  blood  had  been  somewhat  absorbed,  a  closer  scrutiny  could 
be  made.  The  eyeball  was  discovered  to  have  escaped  into  the 
antrum  from  the  orbit  by  a  hole  in  the  orbital  margin  of  the  upper 
jaw,  big  enough  to  admit  the  finger  easily, — the  axis  of  the  eye 
standing  vertical,  the  cornea  downward. 

The  fragments  of  bone  were  adjusted  as  well  as  possible,  and  the 
eyeball  replaced  in  the  orbit.  It  was  uninjured,  and  vision  was 
perfect. 

About  ten  weeks  after,  by  two  blepharoplastic  operations,  the 
eyelids  were  brought  into  tolerably  good  condition.  They  could  be 
closed,  and  usually  so  remained,  but  could  be  opened  enough  to  ex- 
pose the  cornea  and  permit  sight.  The  globe  was,  however,  per- 
fectly immovable.  About  five  months  after  the  injury,  ulceration 
and  suppuration  of  the  cornea  occurred,  and  the  globe  atrophied. 


CHAPTER     XXX. 

/ 

FRACTURES    OF    THE     MAXILLARY    BONES, 

Fractures  of  the  niaxillarj  bones  may  be  divided  into  two  classes, 
simple  and  complicated.  The  first  applies  to  such  cases  as  are  with- 
out external  or  associate  injury,  implying^a  simple  break  in  the  con- 
tinuity of  the  bone.  The  second  applies  to  cases  associated  with 
comminution  of  the  bone,  to  external  lesions,  injury  to  vessels,  to 
teeth, — in  short,  any  condition  which  alters  the  fracture  from  one 
of  a  simple  to  one  of  a  compound  character. 

The  inferior  maxilla,  from  the  exposure  of  its  position,  from  its 
shape,  and  from  its  office,  is  much  more  liable  to  the  accident  of 
fracture  than  the  superior, — the  accident  being  commonly  the  result 
of  blows,  falls,  kicks,  etc.  These  fractures  will,  in  the  majority  of 
cases,  outside  of  gunshot  injuries,  be  found  associated  with  the 
body  of  the  bone,  the  rami  escaping,  from  the  fact  that  a  force 
brought  to  bear  upon  them  slips  the  articulation  more  easily  than 
it  may  break  the  bone. 

The  weakest  part  of  a  bone  would  most  naturally  be  the  part  to 
yield  in  a  diffused  blow.  In  most  inferior  maxillae  this  weakest 
point  is  found  to  be  the  line  of  the  roots  of  the  canine  teetb  ;  hence 
the  most  frequent  seat  of  fracture  in  the  bone  is  in  this  line,  either 
to  the  right  or  left,  as  influenced  by  the  direction  of  the  force.  This, 
however,  as  would  be  inferred,  applies  to  an  unbroken  dental  arch: 
when  teeth  have  been  lost,  and  the  process  removed,  the  situation 
of  this  weakest  part  is  materially  altered.  In  gunshot  injuries,  acci- 
dents from  the  passage  of  a  wheel  over  the  jaw,  or  similar  applica- 
tions of  force,  fractures  occur,  of  course,  at  the  seat  of  such  appli- 
cations, and  follow  no  rule.  In  the  work  of  Prof.  Hamilton  on 
Fractures,  in  twenty-four  recorded  cases  of  breaks  in  the  inferior 
maxillary  bone,  one  was  perpendicular  through  the  symphysis,  twelve 
were  through  the  body,  five  through  the  angle.  Of  the  twenty-four, 
eleven  were  of  a  double  or  triple  character,  the  direction  of  the  frac- 
ture being  mostly  oblique,  both  as  direction  aoid  the  face  of  the  break 
are  concerned. 

(623) 


624  ORAL  DISEASES  AND   SURGERY. 

It  is  singularly  the  case  that  most  fractures  of  the  body  of  the 
lower  jaw  are  compound,  the  opening  existing  on  the  lingual  aspect : 
this  seems  to  be  the  result  of  the  easy  lacerability  of  the  gum  tissue, 
combined  with  the  quick  displacement  inward  of  the  fractured  part. 
This  exposure  of  the  bone  seems,  in  many  mouths,  to  be  of  no  very 
material  consequence.  In  others,  however,  it  is  quite  the  reverse, 
the  saliva  thus  allowed  to  come  in  contact  with  the  bone  degener- 
ating and  deteriorating  the  tissue. 

Fractures  from  blows  of  the  fist,  or  similar  concentrated  forces,  are 
apt  to  be  single  ;  from  falls,  they  are  apt  to  be  multiple  ;  from  kicks 
of  animals,  comminuted.  A  common  cause  of  fracture,  familiar  to 
every  dentist,  is  found  in  the  extraction  of  teeth  having  large  and 
bifurcating  roots:  luckily,  however,  such  fractures  are  not  of  a  seri- 
ous nature,  generally  being  confined  to  the  alveolar  process,  although 
cases  are  on  record  where  such  accidents  have  been  so  extensive  and 
severe  as  to  cost  the  life  of  the  patient.  Complete  division  in  the 
continuity  is,  however,  rare,  very  few  cases  having  occurred. 

The  symptoms  denotive  of  a  fracture  are  seldom  or  never  obscure. 
There  are,  first,  the  mobility  at  the  break,  and  the  crepitation ;  second, 
when  the  break  exists  in  the  body,  there  is  the  loss  of  harmony  in  the 
line  of  the  teeth,  the  short  fragment  being  pulled  upward.  If  the 
fracture  be  multiple,  irregularities  will  be  produced  in  the  line  of  the 
arch,  and  in  the  articulation.  If  the  freed  portion  be  the  anterior  or 
chin  part,  it  will  be  dragged  downward  and  backward  by  the  action 
of  the  genio-hyoid,  hyoglossus,  and  digastric  muscles.  If  it  be  at  the 
line  of  the  cuspid  tooth  and  at  the  upper  portion  of  the  ramus,  the 
fragment  will  be  displaced  inward  by  the  action  of  the  mylo-hyoideus, 
upward  by  the  action  of  the  masseteric,  and  forward  by  the  action 
of  the  pterygoidei.  If  the  fracture  be  single,  and  beneath  the  attach- 
ment of  the  masseter,  crepitation  will  be  present,  but  little  displace- 
ment. If  the  neck  of  the  bone  is  broken,  the  body  is  dragged  for- 
ward by  the  action  of  the  pterygoid,  crepitation  and  mobility  will 
be  very  apparent,  and  much  pain  will  attend  the  movements  of  the 
jaw,  produced  by  the  displacing  action  of  the  temporalis. 

Pain,  soreness,  inability  to  masticate,  inflammatory  phenomena, 
impediment  to  speaking  or  swallowing,  associate  with  and  charac- 
terize the  accident.  In  short,  the  history  of  a  fractured  jaw  is  the 
history  of  a  fracture  anywhere  else,  allowing  for  difi'erences  in  office. 

Fractures  of  the  superior  maxilla  are  quite  infrequent,  and  when 
they  occur,  except  from  extraordinary  causes,  demand  little  attention 
outside  of  that  which  pertains  to  the  injury  as  a  contusion.  Of  such 


FRACTURES  OF  THE  MAXILLARY  BONES.       625 

fractures  I  have  treated  a  number  which  surprises  me,  considering 
the  rarity  of  the  accident  ;  but  in  no  instance,  outside  of  the  alveolar 
fractures,  have  I  met  with  a  displacement  which  required  apparatus 
for  its  cure.  Indeed,  the  cellular  character  of  these  bones,  and  the 
existence  of  the  antra,  permit  of  such  yielding  that  depression  of  the 
substance  of  the  bone  commonly  forms  the  displacement :  hence  the 
associated  frequency  of  caries  with  such  accidents,  the  vitality  of 
the  part  being  low^ered  or  destroyed.  It  is  not,  however,  to  be  un- 
derstood that  displacements  do  not  occur  ;  the  force  of  an  injury  may 
be  great  enough,  as  cases  are  on  record  to  show,  to  displace  the 
bones  in  mass.  In  Mr.  Heath's  work  is  the  record  of  a  case  taken 
from  the  Chirurgical  Treatise  of  Richard  Wiseman,  which  is  a 
marked  example  of  such  displacement.  The  patient  was  a  lad  eight 
years  old,  who  had  received  a  blow  on  the  middle  of  the  face  so 
severe  that  he  appeared  at  first  to  be  dead,  and  afterward  lay  in 
prolonged  coma.  "When,"  says  Mr.  Wiseman,  "I  first  saw  the 
boy,  he  presented  a  strange  aspect,  having  his  face  driven  in,  his 
lower  jaw  projecting  forward.  I  knew  not  where  to  find  any  purchase, 
or  how  to  make  any  extension.  But  after  a  time  he  became  sensible, 
and  was  persuaded  to  open  his  mouth.  I  saw  then  that  the  bones 
of  the  palate  were  driven  so  far  back  that  it  was  impossible  to  pass 
my  fingers  behind  them,  as  I  had  intended;  and  the  extension  could 
be  made  in  no  other  way.  I  extemporized  an  instrument  curved  at 
its  extremity,  which  I  engaged  behind  the  palate,  and,  having  car- 
ried it  a  little  upward,  used  it  to  draw  the  bone  forward,  which  I  did 
without  any  difficulty ;  but  I  had  hardly  withdrawn  the  instrument 
when  the  fractured  portions  went  back  again.  I  theu  contented  my- 
self with  dressing  the  face  with  an  astringent  cerate.  I  likewise 
prescribed  bleeding,  and  some  hours  afterward  I  had  an  instrument 
better  constructed  to  reduce  the  large  mass  of  displaced  bone  to  its 
proper  position.  I  had  it  held  by  the  child's  hand,  by  that  of  its 
mother  or  of  an  assistant,  each  for  a  certain  time.  Nothing  else  was 
done.  Thus,  by  our  united  attention,  the  tonicity  of  the  parts  was 
maintained,  the  callus  was  developed,  and  in  proportion  as  it  became 
solidified  the  parts  became  stronger,  the  face  assumed  a  good  appear- 
ance,— certainly  better  than  could  have  been  hoped  for  after  such 
marked  displacement, — and  the  child  was  entirely  cured." 

A  cast  in  the  Westminster  Hospital,  of  a  frightful  deformity  pro- 
duced by  the  passage  of  a  wagon-wheel  over  the  face  of  a  man  who 
fell  in  the  street,  is  also  alluded  to.  "  Here  the  bones  were  com- 
pletely shattered,  and  the  maxillae  were  torn  from  one  another,  and 

40 


k 


626  ORAL  DISEASES  AND  SURGEBY. 

death  was  instantaneous."  A  case  is  also  recorded  admitted  into  the 
same  hospital  in  1860,  resulting  from  the  overturning  of  a  cab  upon 
the  face  of  its  occupant,  who  at  the  moment  was  leaning  out  of  the 
window  to  direct  the  driver.  Here,  in  addition  to  a  fracture  of  the 
lower  jaw,  a  little  to  the  left  of  the  median  line,  the  nasal  bones  were 
broken,  both  malars  w^ere  loose  and  separated  from  their  attach- 
ments, and  the  left  bone  was  fractured,  as  also  the  external  angular 
process  of  the  frontal  bone.  Though  not  positively  ascertained,  the 
vomer  was  no  doubt  fractured,  and  probably  the  vertical  plate  of 
the  ethmoid  too.  The  case  is  reported  by  Dr.  Fyfes,  in  the  Lancet, 
July  18,  1860.  "It  was  remarkable,"  says  this  gentleman,  "to 
observe  how  movable  the  bones  of  the  face  were.  On  watching  the 
profile  of  the  patient  while  he  was  in  the  act  of  swallowing  food,  the 
whole  of  the  bones  of  the  face  were  observed  to  move  up  and  down 
upon  the  fixed  part  of  the  skull,  as  the  different  parts  were  brought 
into  motion.  It  appeared  as  if  the  integuments  only  retained  them 
in  their  position.  It  was  a  curious  feature  in  the  case,  that  notwith- 
standing the  very  extensive  injury  done,  and  the  violent  character 
of  the  force  which  caused  them,  not  a  single  tooth  was  fractured 
or  misplaced."  This  patient  is  reported  as  having  made  a  perfect 
recovery. 

Of  gunshot  injuries  I  have  had  an  opportunity  to  see  some  marked 
examples.  In  comminuted  fractures  it  has  been  my  practice  to  pick 
away  such  pieces  as  were  completely  detached,  but  to  leave  and 
mould,  when  feasible,  all  others  in  place.  I  never  met  with  trouble 
from  uncontrollable  hemorrhage,  and  generally  found  the  reparative 
energy  sufficient  to  unite  the  comminuted  parts.  In  Circular 
No.  YI.  of  the  Surgeon-General's  Department,  however,  secondary 
hemorrhage  is  noted  as  the  principal  source  of  fatality  in  the  reported 
cases  :  1579  cases  of  fractures  of  the  facial  bones  are  reported  ;  and 
of  these  891  recovered,  HI  died, — the  terminations  of  517  cases 
being  left  still  unaccounted  for. 

The  following  extract,  copied  from  Mr.  Heath's  Essay,  is  from 
the  Official  Medical  and  Surgical  History  of  the  British  Army  in 
the  Crimea:  "Wounds  of  the  face,"  says  the  report,  "though  pre- 
senting often  a  frightful  amount  of  deformity,  are  not  generally  of  so 
serious  a  nature  as  their  first  appearance  might  lead  the  uninitiated 
to  expect.  The  reason  for  this,  apart  from  the  fact  that  the  face 
contains  no  vital  organ,  seems  obviously  to  be  the  very  free  supply 
of  blood  the  part  receives.     From  this  cause,  the  fleshy  structures 


FRACTUBES   OF   THE  MAXILLARY  BONES.       627 

readily  heal,  and  even  the  bones  are  so  supplied  that  extensive 
necrosis  rarely  happens.  The  bony  tissues,  also,  are  softer  than  the 
long  bones  of  the  extremities  ;  and  we  therefore  here  but  seldom 
meet  v^^ith  long  fissures  and  extensive  necrosis  as  a  result  of  concus- 
sion of  bone  so  often  seen  in  them.  This  leads  us  to  the  very  im- 
portant practical  inference,  not  in  this  situation,  as  a  rule,  to  remove 
bony  fragments  unless  the  comminution  be  great,  or  the  fragments 
completely  detached  from  the  soft  parts.  Even  partially  detached 
teeth  will  often  be  found  not  to  have  lost  their  vitality,  and,  if  care- 
fully readjusted,  will  become  useful.  There  is,  indeed,  no  great 
object,  beyond  perhaps  the  present  comfort  of  the  patient,  to  be 
attained  in  removing  either  fragments  of  bone  or  loosened  teeth  in 
the  great  majority  of  instances.  If  they  die  they  become  loose,  and 
are  readily  lifted  away,  without  trouble  to  the  surgeon  and  but  little 
pain  to  the  patient.  This  observation  is  especially  applicable  to 
fractures  of  the  lower  jaw.  Surgeons  in  this  war  have  seen  so  many 
cases  of  badly-fractured  instances  of  this  kind  unite,  and  that  with 
a  very  small  amount  of  deformity,  that  men  of  experience  are  now 
excessively  chary  of  removing  any  portion  of  this  boue  unless  it  has 
become  dead,  or  the  fragment  is  so  situated  as  to  interfere  consider- 
ably with  the  adjustment  of  the  remainder,  or  the  bone  so  much 
comminuted  as  to  give  no  probable  hope  of  its  becoming  consolid- 
ated, or  so  sharply  angular  as  to  threaten  further  injury  to  the  soft 
parts  or  to  interfere  materially  with  their  adjustment  and  retention 
in  situ.  In  these  fractures  of  the  lower  jaw,  much  less  support  and 
adjustment  than  we  are  in  the  habit  of  thinking  advantageous  in 
ordinary  cases  of  fracture  of  it  will  frequently  be  found  necessary, 
or  even  admissible.  A  complicated  apparatus  cannot  be  borne  at 
first,  on  account  of  the  condition  of  the  soft  parts,  and  a  slight  sup- 
port by  a  gutta-percha  or  Startin's  wire  splint,  and  a  split  bandage, 
is  all  that  can  be  done.  Any  attempt  at  ligaturing  the  teeth  is  very 
generally  not  only  useless,  but  injurious ;  and  it  is  surprising  how 
the  parts  often,  as  it  were,  adjust  themselves,  with  but  little  aid 
from  the  surgeon." 

The  treatment  of  a  fractured  jaw  involves  the  indications  to  be 
met,  and  the  mode  or  modes  of  meeting  them.  These  indications 
and  modes  must  of  course  vary  with  almost  every  individual  case. 
For  a  simple  fracture  of  the  inferior  maxillary,  or,  indeed,  as  well 
for  compound  fractures,  the  common  pasteboard  or  gutta-percha 
splint  will  generally  be  found  sufiBcient  and  reasonably  satisfactory. 


628 


ORAL  DISEASES  AND  SURGERY. 


To  make  this  splint,  take  a  piece  of  binder's  board,  or  gutta-percha, 
and  cut  it  as  designated  in  Fig.  230. 

The  board  thus  cut  is  soaked  in  hot  water  until  it  becomes  suf- 
ficiently softened.  The  fracture  is  then  set,  and  the  splint  moulded 
into  shape  and  position.  To  do  this,  it  is  only  necessary  to  lay  the 
centre  of  the  board  beneath  the  chin,  one-half  projecting;  the  wings 
are  now  brought  up  and  moulded  to  the  cheeks ;  next  take  the  pro- 
jecting portion  and  mould  it  around  the  chin  and  sides  of  the  face. 
This  makes  a  complete  cap,  accurately  fitting  the  parts,  and,  when 
dry,  is  uniform  and  unyielding.  To  hold  it  in  position,  a  bandage 
must  be  applied.  The  most  simple  is  a  modification  of  Barton's, 
which  suggested  itself  to  the  author  some  five  or  six  years  back,  and 
which  has  since  been  used  with  much  satisfaction.     The  Barton 

Fig.  230. — Barton's  Bandage. 


A.  Shape  of  the  piece  of  gtltta-percha  for  the  chin.    B.  Tlie  same  moulded  to  the  part, 
— the  ends,  1, 1,  beiog  turned  upward,  and  the  sides,  2,  2,  turned  from  before  backward. 


bandage,  so  generally  employed  in  fractures  of  the  lower  jaw,  con- 
sists of  a  roller  eight  yards  in  length  and  from  one  and  a  half  to  two 
inches  in  width, — following  in  this  latter  respect  the  taste  and  idea 
of  the  operator.  To  apply  this  bandage,  place  the  initial  extremity 
behind  the  left  ear  ;  carry  it  around  the  side  of  the  head,  over  the 
right  parietal  bone  ;  cross  to  the  right  over  the  neighborhood  of  the 
fronto-parietal  suture  ;  carry  down  beneath  the  chin  ;  carry  up  on  the 
opposite  side  ;  cross  on  the  forehead  ;  carry  around  the  left  parietal 
bone,  and  meet  the  beginning  of  the  roller  at  the  occipital  promi- 
nence, or  a  little  below  it ;  continue  the  turns  until  the  bandage  is 
exhausted. 


FRACTURES  OF  THE  MAXILLARY  BONES.       629 


Gibson's  bandage,  used  in  the  same  and  similar  fractures,  mostly 

employed  when  the  break  occurs  at  the  jij^  231. Gibson's  Band- 

angle,    consists    of   three   distinct   turns.  age. 

First.  Place  the  initial  extremity  in  front 
of  the  ear ;  carry  down  beneath  the  chin ; 
pass  up  on  opposite  side,  and  meet  the 
initial  by  passing  over  the  fronto-parietal 
region  far  enough  back  to  prevent  slip- 
ping; repeat  this  turn  three  times.  Second. 
Reverse  in  front  of  and  a  little  above  the 
ear,  and  make  three  turns  around  the  cir- 
cumference of  the  vault.  Third.  End  the 
third  of  these  last  turns  at  the  occiput, 
and  carry  three  times  around  the  occipito-mental  circumference. 
This  is  also  an  eight-yard  roller. 

The  modification  of  the  Barton  bandage,  which  I  find  to  answer 
every  purpose  in  my  own  practice,  and  which  possesses  the  virtues 
of  ease  in  application,  removal,  loosening  and  tightening,  is  applied 
as  follows:  Take  a  strip  of  roller  material,  one  and  one-half  or  two 
inches  wide,  one  and  one-half  yards  in  length.  Standing  behind 
the  patient,  rest  the  chin  on  the  centre  of  this  strip;  carry  the  ends 
up,  cross  on  the  forehead,  carry  around  the  sides  of  the  cranium, 
cross  again  at  the  occiput ;  carry  now  forward,  and  tie,  or  otherwise 
fix,  in  front  of  the  chin. 

In  the  application  of  this  dressing  or  strip,  if  the  parts  about  the 
jaws  are  tender,  it  is  better  to  make  the  termination  somewhere  on 
the  side  of  the  cranium.  To  effect  this,  it  is  only  necessary  to  place 
the  chin,  when  first  resting  the  strip,  nearer  to  one  or  the  other  of  its 
ends.     The  character  of  this  bandage  is  shown  in  Fig.  231. 

A  second  method  of  dressing  a  simple  fracture,  one  which  allows 
the  mouth  to  be  partially  open,  consists  in  making  two  plates,  one 
to  fit  the  upper  teeth,  in  part,  and  the  roof  of  the  mouth,  the  other  to 
cap  a  certain  convenient  number  of  the  lower  teeth.  After  setting 
the  fracture,  these  plates  are  put  in  position,  and  attached  to  each 
other  by  means  of  a  piece  of  wax;  the  attached  plates  are  now  re- 
moved from  the  mouth  and  soldered  together.  This  done,  the  piece 
is  replaced,  and  the  teeth  are  closed  into  the  metal  sockets  ;  the  strip 
bandage  is  next  applied,  and  the  dressing  is  completed.  This  mode 
of  treating  a  fracture  of  the  lower  jaw  I  thought  original  with  my- 
self, but  have  found  it  employed  by  Mr.  Listen,  of  England,  some 
twenty  years  or  more  back,  a  splint  entirely  similar  having  been 


630 


ORAL  DISEASES  AND  SURGERY. 


constructed  by  Mr.  Nasmyth  at  least  five  years  before  the  idea  sug- 
gested itself  to  my  mind. 


Fig.  232. — The  Author's  Bandage. 


In  ally  ordinary  fracture  of  the  lower  jaw,  the  mode  of  dressing 
described  will  be  found  to  meet  all  indications.  In  coniplicated  in- 
juries, it  has  been  the  common  experience  that  rules  are  of  little  or 
no  consequence  ;  the  surgeon  will  find  himself  governed  and  directed 
by  the  peculiarities  of  each  case,  and  will  be  thrown  entirely  upon 
his  own  judgment  and  ingenuity.  Perhaps  no  better  exemplification 
of  this  fact  exists  than  was  exhibited  in  the  practice  of  Dr.  T.  B. 
Gunning,  of  New  York,  in  the  case  of  Secretary  Seward.  The  ideas 
of  Dr.  Gunning  are  multitudinous  in  this  direction  ;  and  while  his 
professional  sense  has  prompted  him  to  the  fullest  exhibit  of  every 
means  he  has  employed,  yet  I  am  well  satisfied,  from  what  I  know 
of  the  profession  at  large,  that  the  arrangements  are  too  complex  to 
come  into  general  use.  The  monograph  published  by  this  gentle- 
man should,  however,  be  in  the  hands  of  every  surgeon.  I  know  of 
few  who  seem  to  have  studied  the  subject  with  more  care  or  who 
have  brought  to  it  more  enthusiasm  and  judgment. 

Fig.  233  represents  the  inner  surface  of  a  very  simple  splint  used 
by  Dr.  Gunning,  which  incloses  all  the  teeth  and  part  of  the  gum  of 
the  lower  jaw.  This  splint,  as  will  be  seen,  would  be  very  applicable 
where  there  were  teeth  on  either  side  of  the  fracture,  where  there 
was  little  tendency  to  vertical  displacement,  and  where  there  was  an 
absence  of  swelling  and  undue  tenderness.  The  holes  marked  A  are 
for  purposes  of  cleanliness,  being  large  enough  to  receive  the  point 
of  a  syringe-nozzle.     When  in  position,  the  jaws  are  to  be  closed, 


FBAGTURES  OF   THE  MAXILLABY  BONES.       631 

the  plate  simply  resting  against  the  upper  jaw  or  teeth  ;  the  strip 
bandage,  as  described,  may  be  thrown  around  the  jaw  and  head. 
Dr.  Gunning  uses  this  splint  without  fastenings,  but  not  unfrequently 
finds  it  necessary  to  secure  it  in  place  by  ligatures,  and  in  some 
instances  by  screws,  which  are  made  to  pass  into  or  between  the 
teeth.  In  cases  of  much  tendency  to  displacement,  Dr.  Gunning  uses 
a  splint  very  similar  to  the  one  which  had  previously  suggested 
itself  to  Mr.  Nasmyth  and  afterward  to  myself, — not  so  good  or 
convenient,  however,  I  am  compelled  to  think,  as  it  unnecessarily 
covers  too  many  teeth,  and  is  thus  made  cumbersome.  This  second 
splint  is  shown  in  Fig.  234. 


Fig.  233. — One  of  Dr.  Gunning's 
Splints. 


Fig.  234.— Dr.  Gunning's 
Second  Splint. 


To  secure  this  splint  in  place,  screws  are  used.  C  represents  an 
opening  left  between  the  conjoined  splints,  for  food,  speech,  etc. ;  D, 
a  channel  for  the  saliva  from  the  parotid  gland  to  enter  the  mouth. 
E  is  a  screw  used  in  the  retention  of  the  piece. 

The  third  modification  of  Dr.  Gunning  (Fig.  235)  consists  in  the 
attachment  to  his  splint  of  wings  of  steel.  This  is  used  in  cases 
where  the  teeth  have  been  lost  in  either  jaw.  F,  upper  wing;  G, 
lower  wing ;  H,  mental  band,  to  hold  the  jaw  up  in  the  splint ;  I, 
neck-strap,  to  keep  the  band  back ;  K,  balance-strap,  to  hold  the  cap 
in  place. 

Fig.  236  is  a  splint  devised  by  Dr.  Gunning  to  answer  general 
cases.  He  suggests,  first,  the  moulding  of  six  or  eight  sizes,  to  be 
kept  ready  for  use,  from  which  one  is  to  be  selected  suitable  for  any 
particular  case  presenting.  The  wings  are  of  malleable  iron,  tinned 
to  prevent  rusting,  and  for  more  ready  soldering.  These  sizes,  he 
thinks,  would  be  sufficient  to  select  from.  The  splint  should  have  a 
handle  in  front,  that  it  may  be  used  as  a  cup  to  take  the  impression 


632 


ORAL  DISEASES  AND  SURGERY. 


of  the  jaw,  the  holes  being  useful  to  allow  a  small  probe  to  be  passed 
through  the  wax  down  to  the  teeth,  thus  allowing  air  to  enter  to 
facilitate  the  removal  of  the  impression,  and,  when  in  use  as  a  splint, 


Fig.  235.— Dr.  Gunning's 
Third  Splint. 


Fig.  236.— Dr.  Gunning's 
Fourth  Splint. 


giving  entrance  to  warm  water,  thrown  from  a  syringe,  to  keep  the 
parts  clean. 

The  splint  should  be  made  to  fit  well  by  bending,  cutting  off  the 
edges,  and  rounding  them  off  smooth.  When  a  tooth  projects  so 
as  to  keep  the  splint  from  fitting,  a  hole  may  be  cut  to  let  it  through, 
if  the  metal  cannot  be  hammered  out.  This  should  all  be  done 
before  taking  the  impression,  as  a  well-fitted  cup  assists  greatly  in 
this  important  matter. 

A  splint  devised  by  Dr.  Bean,  of  Georgia,  used  with  decided 
success  during  the  war  of  the  rebellion,  among  the  Confederate 
troops,  is  in  its  character  similar  in  principle  to  that  of  Dr.  Gunning. 
The  interdental  portion  is  almost  precisely  the  same.  A  modifica- 
tion consists  in  the  use  of  a  mental  compress.  This  is  simply  a 
"piece  of  light  wood,  four  and  a  half  inches  in  length,  three-six- 
teenths of  an  inch  in  thickness,  and  one  inch  and  a  half  in  width 
in  the  middle,  tapering  to  seven-eighths  of  an  inch,  and  round  at 
the  ends,  to  each  of  which  is  attached  a  metallic  side  piece  four  or 
five  inches  in  length  and  from  three-quarters  to  one  inch  in  width, 
also  a  shallow  cup,  fitting  the  apex  of  the  chin.  Incasing  these 
side  pieces  are  temporal  straps,  made  of  stout  cloth,  and  secured 
by  a  strong  cord  at  the  base  of  each  piece. 


FBACTUBES  OF  THE  MAXILLARY  BONES.       63^ 

"  A  bandage,  occipito-frontal,  is  composed  of  a  band  passing 
around  the  head  from  the  forehead  to  the  occipital  protuberance, 
and  secured  by  a  buckle,  one  inch  to  the  right  of  the  median  line 
behind,  of  another  strap  secured  to  the  band  in  front  and  behind, 
and  a  third,  extending  from  the  temporal  buckles  on  either  side  and 
secured  to  the  middle  strap  at  the  point  of  crossing." 

It  is  sometimes  the  case  that  from  comminution,  or  other  causes, 
fractures  of  the  inferior  maxilla,  like  fractures  of  other  bones,  fail  to 
unite.  Necrosis  intervening  frequently  prevents  such  union.  In 
treating  these  cases  the  practitioner  will  find  each  to  have  its  special 
indications.  If  necrosis  exists,  the  exfoliation  of  the  sequestrum 
must  be  awaited.  In  the  few  cases  where  the  vital  forces  seem  at 
fault,  they  are  to  be  stimulated  and  elevated.  If  it  occurs  that  the 
ends  of  the  fragments  have  become  rounded,  and  perhaps  tipped 
with  cartilage,  operative  means  must  of  necessity  be  resorted  to, — 
such  means  varying  with  the  circumstances.  One  plan,  much  ap- 
proved, is  to  pass  through  the  parts  a  seton,  composed  of  several 
strands  of  wire,  to  be  removed  strand  by  strand,  as  inflammation  is 
to  be  modified.  Or,  in  place  of  the  wire,  other  material  may  be 
used,  as  silk,  thread,  tape,  etc.  Another  operation  consists  in  boring 
one  or  more  holes  through  each  of  the  fragments,  and  tying  them 
together  with  sutures  of  wire.  Resecting  the  ends  is  still  another 
means  successfully  employed  by  many.  Irritating  the  ends,  and 
thus  provoking  the  desired  inflammatory  action,  by  rubbing  the 
fragments  together,  is  still  another  plan. 

Attention  to  the  circumstances  of  a  patient  suffering  from  ununited 
fracture  is  important.  A  case  exhibited  several  years  back,  at  the 
clinic  of  the  University  of  Pennsylvania,  by  Professor  Henry  H. 
Smith,  was  plainly  enough  due  to  the  individual  having  confined 
himself  exclusively  to  a  diet  of  potatoes,  such  diet,  in  this  case  at 
least,  being  insufficient  to  accomplish  the  repair.  The  case  of  Mr. 
Seward  comes,  in  many  respects,  within  the  category  of  the  ununiting 
fractures,  the  means  to  overcome  which  constituted  the  skill  em- 
ployed, the  causes  here  being  necrosis  and  non-fixedness. 

Complications,  whatever  their  character,  are  to  be  treated  on 
general  principles.  It  is  impossible  to  direct  any  special  course, 
because  of  such  conditions  being  constant  to  no  rule.  Hemor- 
rhages, so  frequently  alluded  to,  I  have  never  met  with  of  any  par- 
ticular moment.  When  they  do  occur,  however,  they  are  nearly 
always  secondary  in  character,  and  it  may  be  well,  where  possible, 


634  ORAL  DISEASES  AND  SURGERY. 

to  treat  tbera  ia  anticipation :  for  example,  an  injury  which  has 
lacerated  the  facial  arterj  would  perhaps  yield  little  or  no  hemor- 
rhage at  the  time  of  accident ;  yet,  as  the  process  of  sloughing 
should  expose  the  sound  part  of  the  vessel,  hemorrhage  might  be 
profuse  and  alarming  enough.  In  these  and  corresponding  cases 
circumstances  might,  in  special  instances,  justify  one  in  searching 
for  the  ends  of  the  vessels  and  ligating  them.  Injuries  to  the  teeth 
are  to  receive  due  attention  :  it  is  not  by  any  means  every  loosened 
tooth  that  is  to  be  removed,  or  every  displaced  one  that  is  to  be 
looked  on  as  lost  to  usefulness.  Fractures  occurring  about  the  neck 
of  the  inferior  jaw  are  to  have  the  displacements  corrected  by  the 
application  of  such  compresses  as  are  found  to  answer  the  purpose, 
no  matter  how  closely  such  applications  follow  any  special  rules,  or 
how  far  they  depart  from  them.  I  do  not  remember  in  the  course 
of  my  professional  life  ever  having  treated  two  fractures  precisely 
alike. 

In  fractures  of  the  superior  jaw,  complications  are  still  more 
anomalous.  Thus,  I  remember  being  compelled  in  one  case  to  re- 
move the  whole  alveolar  process  of  both  superior  maxillse,  the 
result  of  a  kick  received  from  a  mule.  In  this  case  the  patient  was 
a  man  broken  down  by  drink  and  dissipation.  I  anticipated  by 
compulsion  a  process  which  I  felt  sure  would  have  resulted,  but 
which,  to  have  been  accomplished  per  vias  naturales,  would  have 
cost  the  patient  weeks  of  suffering,  and,  not  unlikely,  life.  I  have 
seen  a  case  of  fracture  of  the  right  upper  maxilla,  where  the  alveolar 
process  (the  fractured  part)  hung  at  least  a  quarter  of  an  inch  below 
the  common  level.  In  this  case  the  part  was  moulded  back  into  its 
place  and  supported  by  a  simple  strip  passing  across  the  jaw  and 
fixed  a  little  beyond  the  fronto-parietal  suture.  In  three  days  the 
part  became  self-supporting,  and  in  two  weeks  the  patient  was  eating 
comparatively  solid  food. 

Gunshot  injuries  of  the  face  and  jaw  are  of  every  conceivable 
variety.  The  surgeon  does  primarily,  in  such  cases,  all  that  he  can, 
and  rests  his  hopes  on  nature. 

With  Hamilton,  we  have  to  remark  that  it  is  "  impossible  to  dis- 
cuss in  detail  all  the  varieties  of  accidents  to  which  the  complicated 
structures  of  the  face  are  exposed  from  balls  or  other  missiles." 

Certain  general  rules  are,  however,  to  be  observed.  For  instance, 
as  suggested  by  this  surgeon,  "  Missiles  entering  and  lodging  in  the 
face  ought  to  be  extracted  as  speedily  as  possible  ;  and,  whenever  it 
is  practicable,  they  should  be  removed  through  the  mouth.     If  per- 


FRACTUBES  OF  THE  MAXILLABY  BONES.       635 

mitted  to  remain,  they  expose  to  the  danger  of  secondary  hemor- 
rhage, and  increase  the  chance  of  subsequent  disfigurement. 

"  Loose  fragments  of  bone  should  be  speedily  replaced,  unless 
very  much  detached  from  the  flesh  and  periosteum,  experience  having 
proven  that  they  unite  in  most  cases  with  facility. 

"  No  piece  of  skin  which  is  torn  up  should  ever  be  removed  unless 
it  is  absolutely  dead;  but  it  should  be  laid  back  carefully  in  place, 
and  retained  either  by  a  hw  delicate  sutures,  or  by  some  other  gentle 
means  of  support.  Tight  ligatures  and  firm  straps  of  adhesive 
plaster  are  apt  to  bind  the  tissues  and  destroy  their  little  remaining 
vitality.  The  best  means  of  supporting  a  fragment  of  skin  in  place, 
in  many  cases,  is  to  lay  upon  it  a  thin  piece  of  lint  smeared  with 
cerate,  and  over  this  a  pledget  of  cotton-batting,  securing  the  whole 
with  adhesive  plaster  or  a  roller. 

"As  soon  as  the  inflammation  and  consequent  induration  have 
completely  disappeared,  and  not  before,  it  will  be  proper  to  make 
the  final  anaplastic  operations." 

An  addendum  to  these  suggestions  of  Dr.  Hamilton  is  to  be  made 
by  directing  attention  to  the  necessity  of  controlling  and  combating 
inflammation.  To  this  end  cold  water  is  to  be  freely  used  locally, 
saturated  cloths  being  renewed  as  the  temperature  is  elevated  ;  or 
the  water  may  have  to  be  medicated,  acetate  of  lead  and  laudanum 
generally  being  added.  A  very  admirable  antiphlogistic  applica- 
tion is  prepared  by  adding  to  ^xvj  of  water  5ij  of  the  former  and 
^ij  of  the  latter.  If  a  patient  should  be  robust  and  plethoric,  it 
will  in  most  cases  be  advisable  to  assist  the  local  treatment  by 
cathartics, — sulphate  of  magnesia  or  the  ordinary  Seidlitz  powder 
being  employed. 

Imperfectly  treated  fractures  not  unfrequently  induce  so  much 
discomfort  as  to  warrant  secondary  fracture.  As  an  illustration, 
the  following  case  may  be  cited  :  T.  H.,  an  employe  on  the  Camden 
and  Amboy  Railroad,  received  a  double  fracture  of  the  inferior  jaw, 
by  being  in  some  way  jammed  between  two  cars  while  in  the  dis- 
charge of  his  duties, — one  break  being  on  the  line  separating  the 
second  and  third  molar  teeth,  the  other,  the  line  of  the  cuspis  root  of 
same  side.  A  treatment  resorted  to  failed  to  retain  the  intermediate 
part  in  place,  so  that  in  uniting  the  teeth  lay  flatwise,  presenting 
the  buccal  face  as  an  articulating  surface. 

Deciding  upon  the  propriety  of  an  attempted  correction,  the  bone 
was  rebroken  through  the  unsolidified  callus,  and  the  depressed  por- 
tion, being  raised  into  position,  was  retained  by  a  silver  splint, — 


636  ORAL  DISEASES  AND  SURGERY. 

this  splint  being  made  and  applied  exactly  as  described  on  page  621. 
As  a  consequence  of  the  injury  inflicted,  several  pieces  of  the  callus 
necrosed  and  came  away ;  but  the  daily  injection  of  the  parts  with  a 
much-diluted  compound  tincture  of  capsicum  resulted,  in  the  course 
of  six  weeks,  in  such  solidification  of  the  parts  in  their  new  position 
as  to  permit  the  disuse  of  the  splints, — terminating  in  a  cure  most 
satisfactory  to  all  concerned. 


CHAPTEH  XXXL 

DISLOCATION   OF   THE   INFERIOR  MAXILLA, 

The  frequency  of  this  accident,  the  terror  which  it  excites,  and 
the  harm  resulting  when  not  properly  cared  for,  give  to  it  an  impor- 
tance which  renders  a  careful  appreciation  of  it  a  matter  of  much 
concern. 

There  are  four  forms  of  submaxillary  displacement:  complete  dis- 
location, incomplete,  bilateral,  and  unilateral.  In  the  first  of  these, 
one  or  both  condyloid  processes  have  slipped  fully  out  of  the  glen- 
oid fossae  and  rest  entirely  in  front  of  the  articulating  eminence, 
as  exhibited  in  the  view, 

Fig.  237.— Complete  Dislocation  of  Jaw. 


In  the  second,  the  condyle  rests  upon  the  interarticular  fibro* 
cartil&ge,  directly  over  the  articulating  eminence,  and  will  remain 
fixed,  or  may  fall  backward  or  forward  as  directed  by  accident, 
not  being  retained  in  its  position,  as  is  frequently  thought,  by  the 
coronoid  process  being  hooked  under  the  malar  bones,  but  resting, 
as  it  were,  upon  a  point,  with  complete  balance  in  the  muscular 
structures. 

A  bilateral  luxation  is  a  displacement  of  both  condyles,  and  is  of 
somewhat  more  frequent  occurrence  than  the  unilateral,  or  displace- 
ment of  one  side. 

(637) 


638  ORAL  DISEASES  AND  SURGERY. 

The  diagnosis  of  a  luxation  is  an  exceedingly  simple  matter.  An 
open  mouth,  with  inability  to  close  it,  the  lower  jaw  thrust  forward  in 
a  straight  line,  or  otherwise  turned  to  the  right  or  left,  according  to 
the  accident,  indicates  a  luxation  of  bilateral  or  unilateral  character. 

The  exciting  ca'uses  of  dislocation  are  various  :  yawning,  vomiting, 
putting  large  bodies  into  the  mouth,  blows  received  upon  the  chin 
from  above  downward,  or  in  front,  while  the  mouth  is  open  ;  the 
extracting  of  teeth,  or  extending  the  jaws  widely  for  the  convenient 
filling  of  them.  The  first  case  I  ever  met  with  occurred  in  a  middle- 
aged  man  while  laughing  immoderately. 

The  predisposing  cause  of  the  accident  resides  in  a  general  or 
special  laxity  of  the  articular  connections:  thus,  all  are  acquainted 
with  persons  who  without  effort  will  dislocate  a  finger  or  a  toe.  I 
have  met  with  instances  where  the  operation  of  removing  a  tooth 
was  always  attended  with  unilateral  luxation  unless  a  mento-occi- 
pital  sling  was  used. 

What  is  the  condition  of  the  parts  in  luxation  ?  By  placing  the 
finger  immediately  in  front  of  the  tragus  of  the  ear  when  the  mouth 
is  closed,  and  carrying  it  forward  along  the  zygoma,  the  surface  is 
found  to  be  a  plane.  If  the  finger  is  kept  on  the  surface,  and  the 
mouth  opened,  it  is  felt  to  drop  into  a  fossa.  This  fossa  is  the  glen- 
oid ;  the  concave  rim  above  is  the  border  of  the  cavity ;  the  rounded 
prominence  below  is  the  condyle  of  the  lower  jaw.  Placing  the  jaw 
of  the  cadaver  in  this  position,  and  dissecting  down  to  the  articulation, 
the  condyle  is  found  slipped  forward,  resting  upon  the  interarticular 
fibro-cartilage ;  the  fossa  has  been  partially  vacated,  and  the  bone 
rests  against  the  articulating  eminence.  If  now  the  condyle  is  dragged 
downward  and  forward  over  the  eminence,  the  glenoid  cavity  will  be 
found  completely  vacated,  and,  unless  by  manipulation,  the  condyle 
cannot  be  restored ;  laying  back  now  the  soft  parts,  the  cavity  in 
front  of  the  tragus  will  be  found  greatly  increased,  the  finger  falling 
into  the  unoccupied  fossa.  (An  added  diagnostic  sign  is  then  found 
to  be  increased  depth  and  size  of  the  fossa  in  front  of  the  ear:  this  it 
is  desirable  to  remember,  as  a  fracture  of  the  neck  might  simulate  a 
luxation.)  Returning  to  the  examination,  we  find  that  to  reduce 
the  dislocation  it  is  necessary  to  depress  the  head  of  the  bone  below 
the  level  of  the  articulating  eminence,  which,  now  being  back  of  the 
condyle,  serves  to  fix  it  in  its  abnormal  position,  as  originally  it 
was  the  means  of  its  retention  in  place.  But  we  pass  to  the  con- 
sideration of  the  associate  parts  :  the  capsular  ligament  we  do  not 
find  torn,  as  a  rule,  but  stretched  and  elongated ;  the  lateral  liga- 


DISLOCATION  OF  THE  INFERIOR  MAXILLA.     639 

ments  do  not  seem  particularly  interfered  with,  and  impress  us  as 
having  little  influence  in  the  matter,  one  way  or  another ;  the  tem- 
poral muscle  shows  itself  stretched  and  dragged  forward,  but  is 
seldom  torn  ;  the  pterygoid  and  masseter  are  relaxed. 

Dislocation  is  of  more  frequent  occurrence  in  women  than  in  men, 
is  uncommon  in  children,  and  rare  in  the  robust.  When  a  disloca- 
tion has  existed  for  a  long  time,  there  seems  a  tendency  on  the  part 
of  nature  to  make  some  compromise  with  the  condition  ;  the  jaw 
will  gradually  recover  considerable  of  the  lost  motion,  and  I  have 
seen  cases  where  the  patient  seemed  to  be  able  to  masticate  his 
food  without  the  least  trouble.  The  original  contour  of  the  face  I 
have  never,  however,  seen  entirely  restored. 

A  luxation  of  the  lower  jaw,  like  the  luxation  of  any  other  bone,  if 
left  unreduced,  even  for  a  very  few  days,  will  be  found  difficult  to 
replace ;  the  muscles  become  contracted,  the  condyle  settles  itself  in 
its  new  position,  lymph  is  effused  and  coagulates,  and  the  general 
aspect  and  relations  of  the  joint  are  changed.  A  patient,  however, 
so  situated,  is  not  to  be  left  unassisted,  or  to  the  relief  afforded  by 
nature.  A  satisfactory  practice  in  cases  of  this  kind,  where  a 
luxation  may  not  be  immediately  reduced,  is  found  in  wedging  corks 
between  the  teeth,  forcing  the  back  part  of  the  jaws  as  far  asunder 
as  possible,  and  then  with  a  properly  directed  compress  and  band- 
age approximating  the  anterior  teeth,  and  at  the  same  time  forcing  the 
lower  jaw  backward.  This  manipulation,  assisted  by  the  employ- 
ment of  sorbefacieuts,  not  unfrequeutly  results  in  the  absorption  of 
the  semi-organized  lymph  and  a  consequent  ability  in  the  bone  to 
reoccupy  its  original  cavity. 

Reduction  of  a  luxated  jaw  has  been  accomplished  as  long  as 
ninety-eight  days  after  the  occurrence  of  the  accident. 

Subluxations  are  of  very  common  occurrence,  particularly  among 
weak  women  of  easy  means  and  luxurious  lives.  In  England,  at- 
tention was  first  directed  to  the  condition  by  Sir  Astley  Cooper ;  in 
this  country  it  certainly  has  needed  no  particular  one  to  discover  it, — 
a  proof,  perhaps,  of  the  physical  superiority  of  English  over  Amer- 
ican ladies.  This  condition  depends,  evidently  enough,  upon  a  laxity 
of  the  ligaments,  and  perhaps  more  particularly  on  the  weakness  of 
the  muscles  of  the  part.  In  yawning,  or  not  unfrequently  in  ordi- 
nary mastication,  the  condyle  will  slip  forward  on  the  articulating 
eminence,  and,  for  a  moment,  the  mouth  cannot  be  closed,  requiring, 
in  many  cases,  the  assistance  of  the  hand  to  effect  it.  Depending  on 
weakness,  a  permanent  cure  is  only  to  be  looked  for  as  a  higher  and 


640  ORAL  DISEASES  AND  SURGERY. 

stauncher  vitality  is  secured.  Tlius,  such  a  tendency  and  condition 
are  to  be  treated  by  cold  bathing,  tonic  medication,  exercise,  etc. 
In  the  case  of  a  lady  liable  to  such  luxation,  and  who  was  made 
very  nervous  by  its  occurrence,  the  accident  was  entirely  guarded 
against  by  the  patient  wearing  the  occipito-mental  caps  and  bands. 
I  was  once  consulted  by  a  lady  who  was  awakened  almost  every 
night  by  the  peculiar  and  unbearable  pain  attendant  on  such  slipping 
of  the  condyle  during  the  relaxation  of  sleep. 

Dislocations  associated  with  fracture  are,  happily,  of  very  rare  oc- 
currence. I  myself  have  never  seen  a  case,  unless,  indeed,  it  existed 
in  association  with  certain  gunshot  wounds,  when  an  appreciation  of 
the  condition,  if  existing,  would  have  been  of  very  little  moment. 
Delamotte  records  a  case  where,  in  the  person  of  a  girl,  double  lux- 
ation existed  with  fracture  of  the  body  of  the  bone.  Another  is 
recorded  by  Roberts,  where  the  body  was  broken  in  front  of  the  right 
ramus,  and  the  condyle  dislocated  outward.  A  third  case  (Heath) 
is  reported  in  the  Dublin  Medical  Gazette,  and  "  occurred  in  a  boy 
of ■  eight,  who  suffered  a  fracture  at  the  symphysis,  with  dislocation 
of  the  left  condyle  upward  and  backward.  There  was  bleeding  from 
the  ear,  and  the  chin  was  much  retracted  and  turned  to  the  left;  the 
mouth  was  open,  but  could  be  closed,  and  it  was  then  observed  that 
the  lower  molars  overlapped  the  upper,  but  that  the  lower  incisors 
were  at  least  one  inch  behind  the  upper.  Reduction  was  easily 
effected,  and  the  case  did  well." 

Luxations  are  sometimes  congenital.  The  first  case  of  this  kind 
was  noticed  by  Mr.  Robert  Smith,  of  Dublin,  who  gives  with  mi- 
nuteness the  results  of  his  dissection.  The  patient,  an  idiot  from 
infancy,  died  at  the  age  of  thirty -eight.  The  luxation  existed  on  the 
right  side,  which  was  remarkably  deformed,  having  a  singularly  hol- 
low appearance,  which  strikingly  contrasted  with  that  of  the  sound 
one,  which  was  unusually  full  and  plump.  The  extremity  of  the 
finger  could  be  readily  pressed  between  the  posterior  margin  of  the 
jaw  and  the  auditory  canal,  owing,  as  was  found  on  dissection,  to 
the  absence  of  the  condyle  of  the  bone,  which  was,  in  fact,  greatly 
atrophied  nearly  as  far  forward  as  the  symphysis.  There  was  no 
interarticular  cartilage  or  distinct  capsular  ligament,  and  the  mas- 
seter,  pterygoid,  and  temporal  muscles  were  much  wasted.  The 
temporal,  malar,  superior  maxillary,  and  sphenoid  bones  were  im- 
perfectly developed,  and  the  glenoid  cavity  existed  merely  in  a  rudi- 
mentary state. 

Treatment  of  Luxation. — By  referring  back  to  Fig.  237,  it  will  be 


DISLOCATION  OF  THE  INFERIOR  MAXILLA.      641 

plainly  evident  that  the  reduction  of  a  disarticulated  condyle  con- 
sists in  getting  it  back  of  the  eniineutia  articularis.  How  best  to  do 
this  is  the  question. 

1st.  Wrap  the  thumb  in  delicate  napkins,  seat  the  patient  on  a 
strong  chair,  and,  standing  behind  him,  rest  his  head  against  your 
person  ;  place  now  the  protected  thumbs  upon  his  inferior  molar 
teeth,  and  with  main  strength  force  the  jaw  directly  downward  and 
a  little  backward  :  the  moment  you  have  depressed  the  articulating 
face  of  the  condyle,  it  will  be  felt  to  be  dragged  into  place.  The 
amount  of  force  required  to  depress  the  condyle  depends  entirely 
upon  the  muscular  tone  of  the  individual.  In  some  cases  the  reduc- 
tion is  effected  almost  before  you  are  aware  of  having  exerted  any 
pressure ;  in  others  it  cannot  be  secured  without  the  assistance  of 
mechanical  appliances. 

Fig.  238. 


2d.  Failing  to  reduce  a  luxation  standing  behind  a  patient,  reverse 
the  position,  resting  the  head  against  an  assistant. 

3d.  Take  corks,  one  or  two,  according  as  the  luxation  is  single  or 
double,  force  them  between  the  wisdom-teeth  of  the  upper  and  the 
lower  jaw  as  firmly  and  fixedly  as  possible  ;  now  gradually  force  the 
chin  forward  and  upward,  using  either  the  hands,  or  a  tourniquet 
applied  around  the  head. 

4th.  Take  a  piece  of  wood  about  a  foot  in  length,  place  one  end 
upon  the  molar  teeth  of  the  luxated  side,  make  a  fulcrum  of  the 
molar  teeth  of  the  upper  jaw  of  the  opposite  side,  and  elevate  the 
end  held  in  the  hand.  If  the  luxation  is  double,  reduce  one  side  at 
a  time.    In  the  use  of  this  lever,  I  have  secured  the  result  more  easily 

41 


642 


ORAL  DISEASES  AND   SURGERY. 


Fui.  239. 


by  resting  the  centre  of  the  piece  of  wood  upon  the  molar  teeth  of 
the  side  to  be  reduced,  carrying  the  end  downward.  I  think  it  will 
be  found  the  most  satisfactory  application  of  the  power. 

The  forceps  invented  by  Stromeyer  yields  a  powerful  leverage. 
This  consists  of  two  blades  so  expanded  at  thfe  extremities  as  to  fit, 
as  Avell  as  may  be,  the  dental  arches,  these  blades  being  covered 
with  leather  ;  a  spring  between  the  handles  throws  them  apart, 
thus  closing  the  blades.  Reduction  is  attempted  in  two  ways.  Intro- 
ducing the  padded  blades  so  that  each  shall  rest  upon  its  proper  tooth 
or  teeth, — the  third  and  second  molars, — the  handles  are  grasped 
in  the  hands  of  the  operator  and  gradually  brought  together;  when 
the  blades  have  thus  been  so  far  separated  that  it  is  inferred  that  the 
face  of  the  condyle  is  below  the  level  of  the  obstructing  eminence, 
the  jaw  is  to  be  pushed  forcibly  backward  into  its  place  by  an 
assistant. 

Another  method  of  using  this  instrument  is  the  employment  of 
a  screw  and    nut  which   passes    between   the   blades :    a    delicate 

wrench  fits  this  nut,  and  through 
its  instrumentality  the  handles  are 
gradually  screwed  together,  sepa- 
rating of  course  the  blades.  The 
manipulation  of  pushing  back  the 
jaw,  Stromeyer  suggests,  should  be 
efi'ected  at  the  same  moment  as  the 
sudden  closing  of  the  blades.  Even 
better,  however,  than  the  Stro- 
me^'er  forceps  is  the  instrument 
figured  on  page  207.  With  this  it 
is  easy  to  secure  the  required  de- 
pression, when  the  condyle,  not 
unlikely,  is  found  to  slip  into  place 
of  its  own  accord. 

5th.  Still  another  method  is  that 
known  as  Xelaton's.  To  practice 
this,  the  patient  is  seated  upon  a 
common  chair,  and  the  surgeon, 
standing  behind,  fixes  his  thumbs 
upon  the  nape  of  the  neck,  while 
with  his  fingers  he  pushes  the  jaw  forward  and  downward  by 
pressure  exerted  upon  the  coronoid  prominences. 

6th.  Anaesthesia. — In  recent  cases  the  anaesthetic  agents  may  not 


A'ertico-JIeulHl  Sling  or  CiiiJ. 


DISLOCATION  OF  THE  INFEBIOR  MAXILLA.     643 

be  required,  although  there  is  seldom  objection  to  their  employment. 
In  cases,  however,  of  any  standing,  or  in  muscular  persons,  it  often 
happens  that  it  is  impossible  to  succeed  in  the  reduction  without 
the  aid  of  relaxing  agents;  while,  again,  the  formation  of  adhe- 
sions will  be  found  to  make  attempts  at  reduction  both  painful  and 
formidable. 

A  luxation  having  been  reduced,  it  becomes  necessary  to  give 
support  to  the  parts,  and  insure  for  a  time  against  the  possibility  of 
the  mouth  being  too  widely  opened.  This  is  most  conveniently  in- 
sured through  the  use  of  a  vertico-mental  sling  made  with  elastic 
straps. 


CHAPTER    XXXII. 

OZ^NA. 

The  term  ozsena,  like  the  term  epulis,  is  a  somewhat  indefinite 
one,  and  is  to  be  first  considered  in  the  width  of  its  signification. 

Ozsena  is  from  the  Greek  6!^rj,  signifying  "  stench,"  and  the  term 
is,  therefore,  in  reality,  applicable  to  any  ill-smelling  condition.  By 
universal  consent,  however,  it  has  been  restricted  in  its  application 
to  foul  conditions  about  the  nares  and  associate  parts,  accompanied 
with  offensive  discharge.  The  study  of  ozsena,  then,  it  will  be  seen, 
is  the  study  of  various  conditions,  and  may  be  considered  under  the 
following  heads: 

1.  Accumulation  and  degeneration  of  the  common  antral  secretion. 

2.  Degenerated  pus  from  tooth-abscess  discharging  into  the 
antrum. 

3.  Ulceration  of  mucous  membrane  of  the  antrum. 

4.  Deteriorated  secretions  from  constitutional  causes. 

5.  Caries  of  the  osseous  walls  of  the  antrum. 

6.  Ulceration  of  the  mucous  membrane  of  the  nares. 

1.  Caries  and  necrosis  of  the  osseous  boundaries  of  the  nares. 

8.  Lodgment  and  retention  of  foreign  bodies. 

1.  The  first  of  these  conditions  is  most  frequently  observed  in  con- 
nection with  the  ordinary  cold  in  the  head.  The  outlet  of  the  antrum, 
it  will  be  remembered,  is  by  an  opening  about  the  size  of  a  goose-quill 
into  the  middle  meatus,  which  opening  is  circumscribed  by  mucous 
membrane,  and  which  membrane,  as  the  result  of  congestion,  can 
very  readily  occlude  this  outlet ;  the  parts  being  in  this  condition,  it 
may  happen  that  the  pent-up  mucus  degenerates  and  decomposes, 
so  that,  on  the  subsidence  of  the  swelling,  the  escaping  discharges 
present  this  ofi'ensive  odor.  To  diagnose  this  character  of  ozaena,  it 
is  only  necessary  to  connect  it  with  the  preceding  inflammation,  with 
the  absence  of  specific  conditions,  and  with  the  readiness  with  which 
it  yields  to- simple  treatment.  Of  course  there  would  have  been  a 
preliminary  feeling  of  the  sense  of  congestion  on  the  part  of  the 
patient;  he  would  have  had,  to  express  it  most  simply,  a  cold  in  the 
(6i4) 


OZMNA.  645 

head,  and  this  cold,  with  its  sense  of  dryness  and  consti'iction,  would 
have  grown  worse,  until,  with  the  appearance  of  the  discharge,  he 
would  have  experienced  a  sense  of  relief, — the  discharge  implying  the 
passing  away  of  the  congestion  and  the  restoration  of  the  normal 
circulation  and  secretion. 

To  cure  this  form  of  oztena  requires  very  little  treatment, — indeed, 
in  most  eases  no  treatment  at  all.  I  am  in  the  habit,  when  the 
discharge  continues  longer  than  two  or  three  days,  of  directing  the 
sniffing  up  the  nostril  of  the  affected  side  some  such  combination  as 
the  following: 

B. — JEtheris  sulphatis,  ^j ; 

Tincturae  iodinii,  ^ij  ; 

Olei  juniperi,  5j-     M, 

If  this  fails  to  check  the  discharge,  I  then  employ  such  constitu- 
tional treatment  as  seems  indicated.  Patients  in  whom  such  dis- 
charge exists  belong  to  one  of  two  classes,  the  plethoric  or  the 
aoEemic.  With  the  first,  the  treatment  demanded  is  depletory;  a 
dose  or  two  of  sulphate  of  magnesia  will  generally  be  all  that  is 
demanded  ;  although  in  a  few  instances  I  have  found  it  necessary 
to  deplete  from  the  veins.  With  the  second  class — and  this  is  by 
far  the  more  numerous — we  have  the  mucous  membrane  of  the  part 
falling  into  a  condition  analogous  to  the  urethritis  of  chronic  gonor- 
rhoea ;  in  these  cases  tonics  are  at  once  to  be  resorted  to,  and  the 
common  combination  of  iron  and  quinia  is  perhaps  the  best  that  can 
be  prescribed  : 

R. — Tincturas  ferri  chloridi,  §j ; 
Quiniae  sulphatis,  5j-     M. 
Sig. — Fifteen  drops  in  water  every  three  hours. 

2.  Fetid  discharges  depending  on  tooth-abscesses — abscesses 
which  discharge  into  the  antrum — find  their  cure,  as  a  rule,  imme- 
diately on  the  extraction  of  the  diseased  tooth.  If  this  should  not, 
however,  prove  to  be  the  case,  then  injections  are  to  be  made 
through  the  tooth  alveolus.  Iodine  is  an  admirable  base  for  all 
such  injections.  My  own  practice  would  be  first  to  control  the 
odor  with  the  permanganate  of  potash. 

B. — Potassae  permanganatis,  5ss — j  ;       .  - 

Aquae,  oviij.     M. 
Inject  as  occasion  requires. 


646  ORAL  DISEASES  AND  SURGERY. 

It  would  most  likely  be  quite  sufficient  to  use  this  injection  three 
times  a  day.     After  it  the  following  should  be  thrown  in : 

B. — Tincturae  iodinii,  3j ; 
Glycerinse,  3] ; 
Acidi  tauuici,  5ss ; 
Aquae  Coloniae,  5j ; 
Aquae  destillatae,  ^iij.     M. 


Or, 
Or, 
Or, 


B. — Tincturae  capsici  compositae,  ^ss; 
Aquae  rosae,  ^viij.     M. 

B. — Argenti  nitratis,  gr.  xxx; 
Aquae,  o^j-     ^I- 

B. — Vini  opii,  5j ; 

Yinl  aroniatici,  3j ; 
Aquae,  ^\g.     M. 

Indeed,  any  stimulant  preparation  may  be  resorted  to ;  although  I 
incline  to  believe  that  iodine  acts  the  most  happily. 

3.  Ozaena  from  ulceration  of  the  mucous  membrane  of  the  antrum 
is  not,  so  far  as  my  experience  allows  me  to  judge,  a  condition  of  fre- 
quent occurrence  ;  without  doubt  this  is  the  case  where  no  specific 
disease,  as  syphilis,  scrofula,  or  scurv}',  exists,  so  that,  meeting 
with  such  ozaena,  we  naturally  at  once  revert  to  the  constitutional 
condition.  To  discover  an  ulcer  within  the  antrum  is  a  matter  for 
diagnosis  by  exclusion,  and  thus  to  discover  it  is  not  at  all  a  difficult 
matter.  If  there  are  no  diseased  teeth  or  teeth-roots,  no  nasal 
ulceration,  no  antral  dropsy,  no  acute  preliminary  conditions;  if  the 
fetid  matter  flows  most  freely  when  the  suspected  antrum  overlies 
its  nasal  outlet,  then  we  ^vill  generally  be  right  in  inferring  an  ulcer 
of  the  antrum  ;  but  an  ulcer  in  the  antrum  is  not  necessarily  a 
cause  of  ozaena.  To  give  this  fetid  odor,  it  must  be  an  unhealthy 
ulcer,  by  which  is  meant  that  it  teuds  to  degenerate  its  granulations, 
rather  than  to  organize  them.  An  ulcer,  says  Mr.  Cooper,  may  be 
defined  to  be  "  a  granulating  surface,  secreting  matter;"  and  this  is 
certainly  true  of  most  ulcers,  particularly  if  we  replace  the  term  se- 
creting with  the  term  making;  for  the  matter  given  off  is,  I  imagine, 
nothing  but  degenerated  lymph-corpuscles,  to  which  the  parts  lacked 
strength  to  give  force  of  organization.  A  healthy  ulcer  may  be 
seen  in  any  accidental  sore  tending  to  rapid  self-cure :  there  is  here 


OZ^NA.  647 

little  or  perhaps  no  matter,  for  the  reason  that  every  particle  of  the 
exuded  lymph  of  repair  has  in  it  vitality  sufficient  for  its  organiza- 
tion. An  unhealthy  ulcer,  on  the  contrary, — and  by  such  an  ulcer 
we  mean  an  adynamic  one, — gives  oif  more  or  less  pus ;  it  throws 
out  its  reparative  lymph  just  as  does  the  healthy  one,  but  the  via- 
bility of  such  lymph  diff'ers  materially  from  the  exudation  of  the 
former  ulcer.  Thus,  according  to  the  nature  and  character  of  such 
degeneration,  we  have  the  produced  pus :  ichorous,  a  thin,  watery, 
acrid  discharge;  scrofulous,  a  cheesy,  curdlike  pus;  sanious,  a  thin, 
sizy  dischai'ge  ;  glutinous  and  viscid,  as  in  sordes,  etc. 

Now,  whether  any  or  all  of  these  kinds  of  ulcers  should  give  us  the 
fetor  of  ozaena,  would  depend  on  circumstances;  not  the  least  im- 
portant of  which  would  be  the  state  of  the  atmosphere,  and  the 
cleanliness  preserved.  Laudable  pus,  issuing  from  a  healthy  wound, 
w']]\,  in  hot  weather,  become  quite  offensive  in  a  very  short  time,  as 
is,  unfortunately,  too  freely  illustrated  in  hospital  practice.  Certain 
ulcers  are,  however,  in  themselves  ofiTensive.  Every  one  has  had 
occasion  to  observe,  at  some  time  or  other,  the  disgusting  odor 
arising  from  the  saliva  of  particular  persons, — constitutional  ozaena 
it  may  with  most  propriety  be  termed.  I  recall,  even  to  this  day,  a 
certain  schoolmaster,  the  odor  of  whose  spittle,  employed  to  rub 
sums  from  my  slate,  always  made  me  sick.  This  kind  of  Siiliva, 
and  this  odorous  ulcer,  belong  to  the  alkaline  class  of  people.  Give 
such  persons  acid ;  they  always  need  it ;  I  never  knew  an  exception. 

A  simple  ulcer  of  the  sinus — that  is,  one  not  associated  with 
osseous  diseases^is  to  be  treated  in  the  twofold  direction  of  its  con- 
stitutional and  its  local  requirements.  To  treat  an  ulcer  justly,  calls 
for  an  understanding  of  the  conditions  on  which  ulcers  depend  ;  and 
as  ulcers  of  various  signification  so  frequently  present  themselves 
about  the  mouth  and  throat,  it  may  not  be  a  digression  to  make  a 
hasty  review  of  so  enlarged  and  important  a  subject. 

Ulceration  is  the  absorption  or  the  breaking  down  of  some  con- 
stituent part  of  the  body.  Its  great  cause  is  inflammation.  Inflam- 
mation is  always  preceded  and  excited  by  irritation.  The  term  irri- 
tation is  a  comprehensive  one,  and  covers  every  source  of  offense  to 
the  human  body.  Thus,  one  man  has  an  ulcer,  the  result  of  an  in- 
flammation excited  and  perhaps  kept  up  by  the  presence  of  some 
foreign  body,  as,  for  example,  a  ball,  a  splinter  of  wood,  a  particle 
of  dust,  etc.  An  ulcer,  says  Richerand,  is  from  a  cause  inherent  in 
the  economy,  and  differs  from  a  wound,  which  is  always  idiopathic, 
in  being  symptomatic.     A  second  man  has  an  ulcer,  the  result  of 


648  OBAL  DISEASES  AND   SURGERY. 

a  localized  inflammation,  predisposed  by  the  presence  within  his 
system  of  some  specific  taint.  These  ulcers,  a  glance  would  exhibit, 
must  vary  widely  in  their  character,  and  even  more  so  in  the  treat- 
ment demanded  for  their  cure.  Thus  it  is  that  we  speak  of,  and 
think  about,  ulcers  in  the  way  of  their  signification.  We  have  simple 
purulent  ulcers,  venereal  ulcers,  scrofulous  ulcers,  scorbutic,  varicose, 
and  cancerous  ulcers;  the  character  of  each  being  expressed  by  its 
adjectival  prefix.  A  simple  purulent  ulcer  is  a  sore,  the  result  of 
some  local  accident,  and  is,  most  likely,  self-curing;  a  venereal  ulcer 
is  one  excited  and  kept  alive  by  the  presence  in  the  system  of  the 
venereal  poison;  the  scrofulous,  scorbutic,  and  cancerous  alike  de- 
pend on  dyscrasic  conditions;  the  varicose  on  certain  obstructions 
in  the  venous  system,  etc.  To  secure  a  cure  in  the  first  of  these 
classes  of  ulcers,  nothing  more  is  necessary  than  to  protect  them 
from  adverse  influences.  A  varicose  ulcer,  to  be  cured,  must  be 
converted  into  a  simple  one  by  treatment  directed  to  the  trouble 
in  the  circulation;  a  cancerous,  scorbutic,  or  scrofulous  ulcer  is  only 
to  be  permanently  cured  by  obliterating  the  cachexia.  There  is 
nothing  obscure  in  the  appreciation  of  these  facts;  the  difficulty  is 
in  meeting  the  indications.  Ulcers,  it  is  true,  are  presented  under 
a  great  variety  of  names ;  but  these  variations  have  reference  only 
to  varieties  in  expression.  Thus,  the  carious  ulcer  implies  that  the 
condition  is  dependent  on  the  presence  of  dead  or  dying  bone;  a 
callous  ulcer  is  one  having  an  indurated  circumference;  a  fungous 
ulcer  is  oue  where  the  granulations  of  repair  are  in  excess ;  a  sinuous 
ulcer  is  one  constituting  the  orifice  of  a  canal  leading  to  a  deeper 
than  the  manifested  disease  ;  an  irritable  ulcer  is  one  that,  from  in- 
ternal or  external  causes,  has  become  tender  and  excited;  a  phage- 
denic ulcer  is  one  that  tends  to  take  on  gangrenous  action  ;  a  sordid 
ulcer  is  one  discharging  a  dirty-looking  glutinous  matter;  and  so 
on,  each  of  the  many  appellations  being  simply  an  expression  of 
some  distinctive  peculiarity.  Now,  one  man,  having  syphilis,  gets 
a  rheumatism  in  his  joints;  another  gets  an  ulcer  on  his  tibia.  In 
these  two  cases  the  important  features  of  treatment  are,  how- 
ever, to  be  precisely  alike  :  both  patients  must  have  an  antisyphilitic 
medication;  the  local  applications  are  simply  adjuncts.  An  ulcer 
simple  in  its  character,  situated  over  or  upon  some  part  in  frequent 
motion,  is  apt  to  assume  the  irritable  aspect ;  an  ulcer  the  result  of 
an  idiopathic  influence,  if  occurring  on  a  person  of  weak  and  typhoid 
condition,  is  almost  certain  to  assume  the  chronic  or  indolent  form; 
an  ulcer  engrafted  by  external  cause  on  a  depraved  constitution  is 


OZJENA.  649 

always  more  or  less  influenced  by  the  vice,  and  such  vice  must  be 
considered  in  its  treatment ;  and  so,  whatever  may  be  the  extent  of 
the  review,  this  wide  collateral  relationship  keeps  itself  in  the  fore- 
ground. 

To  return,  then,  to  ulcers  in  the  antrum.  We  are  prepared  to 
recognize  that  such  ulcers  may  be  of  various  signification,  and  may, 
for  their  cure,  demand  a  various  character  of  treatment.  So  far  as 
the  odor,  however,  is  concerned,  all  will  benefit  by  the  common  pri- 
mary treatment  of  cleanliness  and  antiseptic  injections.  To  correct 
the  fetor  in  a  chronic  case,  it  generally  becomes  a  necessity  either  to 
trephine  through  the  canine  fossa,  or  to  extract  one  of  the  underlying 
teeth  and  get  into  the  cavity  through  its  alveolus:  the  latter  mode 
is  decidedly  to  be  preferred.  A  plan,  however,  that  may  be  tried, 
consists  in  keeping  a  tuft  of  cotton  or  fine  sponge  in  the  nostril,  and 
frequently  saturating  it  by  the  sniflSng  into  it  of  an  antiseptic.  The 
entrance  into  this  cavity,  however,  through  the  alveolus  of  a  tooth 
is  one  of  the  simplest  procedures  in  surgery,  demanding  only  that 
the  operator  shall  recognize  the  position  of  the  cavity  as  influenced 
by  the  shape  of  the  jaw.  Any  spear-shaped  instrument  will  answer 
to  make  the  opening:  to  keep  it  patulous,  it  is  only  necessary  to 
introduce,  after  each  operation  or  injection,  a  tent  of  cotton  or  sponge. 
As  an  injection,  the  following  combination  may  be  employed  : 

B. — Acidi  carbolici,  gtt.  xx; 

Glycerin  as,  5ss ; 

Acidi  tannici,  gr.  v  ; 

Aquffi,  |vj.     M. 
Or, 

R. — Spiritus  vini,  ^j  ; 

Creasoti,  gtt.  x; 

Aquae,  |vj.     M. 

Or,  as  suggested  on  page  645,  the  permanganate  of  potash  in  the 
proportion  of  from  two  to  ten  grains  to  the  ounce  of  water,  as  indi- 
cated. 

Phenate  of  soda,  combining  as  it  does  antiseptic  and  alterative 
virtues,  is  one  of  the  very  best  injections  that  may  be  employed  in 
these  cases. 

Associated  with  such  antiseptic  treatment,  and  which  we  use  in 
every  case  of  ozsena,  whatever  may  be  its  origin,  we  connect  the 
specific  or  peculiar  treatment  demanded  by  each  special  case, — the 


650  ORAL  DISEASES  AND   SURGERY. 

understanding  of  which  treatment  presupposes  and  necessitates  the 
understanding  of  disease  in  general,  and  can  conform  to  no  special 
rules. 

It  is  true  that  for  certain  diseases  we  have  certain  medicaments 
which  we  have  come,  perhaps  unadvisedly,  to  consider  too  much  in 
the  light  of  specifics.  Thus,  in  syphilis,  the  mercurials  are  much 
depended  on  ;  so  that,  having  an  ulcer  of  such  origin  to  treat,  a  con- 
stitutional medicine  might  be  prescribed,  as  follows : 

R. — Syrupi  ferri  pyrophosphatis,  §vj  ; 

Hydrargyri  chloridi  corrosivi,  gr.  iv.     M. 
Sig. — A  teaspoonful  three  times  a  day. 
Or, 

R. — Hydrargyri  iodidi,  gr.  ij ; 
Potassii  iodidi,  5ij  ; 

Syrupi  sarsaparillae  compositae,  §viij.     M. 
Sig. — A  tablespoonful  three  times  a  day. 

Mercury  is  to  be  considered  as  an  active  force,  striking  at  the 
parasite  of  syphilis,  destroying  it;  and  while  it  is  very  well  thus  to 
kill  such  a  parasite,  it  is  quite  as  well  to  remember  that  the  harm  of 
the  agent  employed  must  be  constantly  met  and  counterbalanced. 
This  we  do  by  keeping  up  and  supporting  the  system,  so  that  I 
think  it  will  commonly  be  found  that  syphilitic  ulcers  require,  quite 
as  much  as  a  specific  medication,  wholesome  food,  fresh  air,  proper 
exercise,  judicious  bathing, — in  short,  the  employment  of  every 
means  that  tends  to  the  maintenance  of  the  general  health. 

In  the  mercurial  ulcer  of  the  antrum — which  is  far  more  common 
than  the  syphilitic,  granting  the  true  syphilitic  to  exist — the  general 
and  local  use  of  the  chlorate  of  potash  is  found  to  act  very  well. 
The  medicine,  dissolved  in  water,  may  be  given  in  doses  of  ten 
grains,  repeated  four  or  five  times  a  day;  the  injection  should  not 
be  less  in  strength  than  a  saturated  solution.  The  character  of  a 
mercurial  ulcer  is  discovered  by  associating  the  local  lesion  with 
the  existing  dyscrasia. 

Scrofulous  ulcers  are  judged  by  the  appearance  of  the  sore,  the 
nature  of  the  discharge,  and  the  existence  of  depression  in  the 
patient  at  large.  A  scrofulous  subject,  while  not  always  bearing 
the  clearest  general  evidences  of  the  disease,  usually  has  some  one 
or  more  features  that  will  allow  us  to  distinguish  the  condition. 
General  features  associated  with  scrofula  may  be  enumerated  as 


OZMNA.  651 

follows :  the  first  manifestation  occurs  generally,  not  always,  at  the 
period  of  first  dentition,  the  symptoms  being  irregular  appetite,  an 
ill-smelling,  inspissated  mucus,  and  swelling  of  the  superficial  glands 
of  the  neck.  Continued  manifestations  advance  with  age,  presenting 
subcutaneous  h^mph  effusion,  particularly  about  the  calves  of  the  legs 
and  the  outside  of  the  thighs ;  various  eruptions,  inflammation,  and 
suppuration  of  joints,  especially  the  hip,  knee,  and  thumb-joints ;  a 
flaccid,  enlarged  condition  of  the  tonsil  glands,  susceptibility  to 
atmospheric  changes,  inability  to  endure  physical  fatigue,  impover- 
ishment of  the  blood,  general  asthenia.  Scrofulous  subjects  are 
generally  languid  in  their  movements,  and  without  impressibility ; 
not  always,  however,  for  it  is  a  well-known  fact  that  many  of  the 
most  precocious  and  bright  persons  end  their  effulgence  in  phthisis. 
In  short,  the  history  of  scrofula  may  be  viewed  as  the  history  of 
phthisis :  it  matters  little,  so  far  as  a  general  efi"ect  upon  an  individual 
is  concerned,  whether  tubercle  deposits  itself  in  the  lung  or  in  the 
ganglia,  or  whether  there  is  deficiency  in  the  developing  force. 

Scrofulous  ulcers  are  always  unhealthy  in  appearance,  being 
covered  with  a  dirty-yellowish  aplastic  matter,  irregular  about  their 
edges,  generally  bluish  or  purple,  more  or  less  undermined,  and  dis- 
charging an  ichorous,  flaky  pus.  Local  stimulation  meets  with  little 
or  no  response,  and,  for  the  reason  of  the  general  deficiency  in 
vitality,  the  parts  around  are  usually  indurated  from  interstitial 
deposits,  chronically  congested,  and  looking  altogether  indolent  and 
ill  conditioned. 

The  treatment  of  scrofulous  as  well  as  of  the  true  tuberculous 
ulceration  is  (in  our  present  knowledge  of  the  disease)  simply  a 
treatment  of  building  up.  Unacquainted  with  any  special  materia 
peccans,  we  direct  our  aim  so  to  lift  up  the  life-forces  that  a  sufii- 
cient  inherent  vitality  may  be  developed  to  throw  off  or  overmaster 
the  depressing  influence.  Exercise,  tonic  medicaments,  cold  bathing, 
salt  and  mountain  air,  rare  or  raw  meats,  generous  liquors, — all  are 
useful  means  to  such  an  end.  Iodide  of  potassium  has  long  had  a 
reputation  in  this  condition ;  also  barium,  iodide  of  iron,  syrup 
of  the  phosphates,  cod-liver  oil,  phosphoric  acid,  etc.  My  own 
individual  experience  is,  that  wrapping  one's  self  in  a  wet  sheet 
on  getting  out  of  bed,  and  securing  vigorous  reaction  by  a  good 
hand-rubbing,  and,  after  such  operation,  drinking  the  yelk  of  a  fresh 
egg  drowned  in  good  brandy  or  whisky,  is  better  than  any  medicine 
proper  yet  prescribed.     Cei'tain  I  am  that  I  have  seen  this  treat- 


652  OBAL  DISEASES  AND  SURGERY. 

ment  do  such  good  as  warrants  the  commendation  these  remarks 
would  give  it.* 

We  always,  however,  do  something  for  a  local  disease,  from 
mere  force  of  habit,  if  for  no  other  reason.  We  can  use  with  these 
ulcers  any  of  the  applications  referred  to  a  few  pages  back,  and  any 
one  of  them  is  about  as  good  as  any  other,  or  we  may  use  them  one 
after  another. 

Syphilitic  ozsena  from  ulceration  of  the  antral  mucous  membrane 
must  be,  as  we  have  remarked,  an  exceedingly  infrequent  affection. 
Not  so,  however,  with  ulceration  from  such  cause  in  the  naris ;  such 
a  condition  is  quite  common.  When  j'ou  have  a  case  in  which  dirty 
clotty  scabs  are  constantly  being  received  into  the  handkerchief,  and 
much  offensive  sanies  is  discharged  from  the  nose,  you  may  feel  well 
satisfied  that  you  have  a  case  of  syphilitic  ulceration,  and  particu- 
larly may  you  rest  satisfied  in  j'our  diagnosis  if  any  evidences  of  the 
disease  exist  in  other  parts  of  the  body.  Syphilitic  ulceration  of  the 
nose  has  frequently  been  confounded  with  a  commencing  polypus ; 
but  the  conditions  are  so  dissimilar  that  only  the  most  culpable  care- 
lessness could  fail  to  distinguish  them.  In  the  first  condition  there 
are  the  fetid  discharge,  and  the  association  with  the  anterior  train 
of  accidents ;  a  scab  soon  conies  away,  and  a  temporary  cessation 
of  the  obstruction  ensues.  In  the  latter  disease  the  obstruction  is 
apt  to  be  gradual  and  continuous;  there  are  no  fetid  clots,  and  no 
anterior  accidents  of  association  ;  blowing  the  nose,  in  the  one  case, 
most  likely  relieves  for  the  moment ;  in  the  second,  it  throws  for- 
ward the  polypus  so  that  we  can  see  and  feel  it. 

Syphilitic  ulcers  within  the  nose  attack  equally  any  location,  and 
possess  the  most  unfortunate  tendency  to  enlarge  and  burrow,  so 
that,  if  not  successfully  combated,  in  a  very  short  time  the  bony 
framework  is  involved,  thus  producing  the  deformities  so  common. 

A  patient  with  a  syphilitic  ulcer  developing  in  his  nose  com- 
plains first  of  a  feeling  of  congestion.  We  come  to  our  conclusions 
because  we  observe  certain  secondarv  indications.  A  few  days,  more 
or  less,  pass,  and  he  is  troubled  with  a  discharge ;  this,  at  first,  is 
very  slightly  or  perhaps  not  at  all  offensive.  Very  soon,  however,  he 
remarks  the  odor,  and  the  discharge,  which  continues  to  increase, 
frequently  becomes  so  profuse  that  twent}^  or  thirty  pocket-handker- 

*  The  author,  for  convenience,  here  combines  the  conditions  of  scrofulosis 
and  tuberculosis,  as  at  present  we  have  but  a  common  treatment  for  them, 
and  thus  nothing  practical  would  be  gained  in  separating  them. 


OZJENA.  653 

chiefs  are  necessary  for  his  daily  use.  Occasionally,  and  sometimes 
very  frequently,  dirty,  gluey  clots  or  scabs  come  away,  and  the 
ulcer,  if  seen,  is  noticed  to  present  a  I'easonably  healthy  look, — 
something,  for  example,  as  a  chancre  would  look  when  only  half 
destroyed  and  casting  off  its  slough.  If  uncombated  and  uncon- 
quered,  the  ulcer  eats  deeper  and  deeper,  until  the  bone  is  reached, 
which,  in  its  turn,  succumbs,  giving  us  caries,  or,  much  more  likely, 
necrosis.  Arrived  at  this  stage,  we  have  indeed  a  most  formidable 
condition,  and  it  is  not  at  all  unlikely  that,  in  defiance  of  every  effort, 
more  or  less  deformity  will  result. 

An  ulcer  situated  in  the  anterior  part  of  the  naris  is  indicated  by 
the  forced  expirations  of  the  patient.  Situated  well  back,  he  relieves 
himself  by  forced  inspirations;  occasionally,  however,  from  the  very 
beginning  the  pituitary  membrane  becomes  so  thickened  and  en- 
gorged that  the  passage  of  air  through  the  tube  is  almost  shut  off: 
in  these  cases  the  trouble  is  indicated  by  excessive  restlessness. 

It  is  not  by  any  means  always  the  case  that  nasal  ostitis  is  sec- 
ondary to  ulceration :  on  the  contrary,  the  cases  are  frequent  enough 
where  the  bone  becomes  primarily  diseased  and  where  the  ulcer  is 
simply  the  associated  lesion.  Syphilitic  ostitis  very  frequently  ends 
in  necrosis,  and  more  particularly  is  this  the  case  where  the  turbi- 
nated bones  are  the  ones  affected.  The  vomer,  however,  is  the  bone 
most  frequently  necrosed  in  syphilis, — that  is  to  say,  the  most  fre- 
quently attacked  ;  and  this  is  brought  about  in  three  ways  :  first, 
from  a  primary  ulceration  of  its  mucous  covering;  secondly,  by  the 
deposition  of  submucous  tubercles  ;  thirdly,  by  the  direct  affection  of 
the  bone.  When  ostitis  attacks  the  vomer  or  any  other  bone,  our 
best  efforts  are  to  be  directed  to  the  resolution  of  the  inflammation. 
To  secure  this  end  we  resort  to  such  local  means  as  seem  indicated 
by  the  peculiar  features  of  the  case.  The  treatment  would  be  that 
applicable  to  inflammation  anywhere ;  it  could  be  influenced  by  the 
temperament  of  the  patient  and  the  stage  of  the  disease.  Locally 
we  have  at  this  time  nothing  to  do  with  its  specific  character:  we 
have  simply  to  treat  a  perverted  condition  of  the  circulation  of  the 
part.  Constitutionally,  however,  its  origin  is  to  attract  our  closest 
scrutiny;  and,  in  connection  with  the  local  remedies  employed,  anti- 
venereals  must  be  depended  upon  as  our  strongest  supports. 

The  diagnosis  of  inflammation  of  the  nasal  boundaries  is  not  diffi- 
cult to  make  out.  When  the  vomer  is  the  bone  attacked,  the  patient 
suffers  from  sharp  pains,  referred  to  the  root  of  the  nose  ;  he  has 
headache,  always  increased  by  the  recumbent  position.     If  the  in- 


654  ORAL  DISEASES  AND  SURGERY. 

flammation  exists  in  the  anterior  part,  pressure  on  the  cartilage 
increases  the  pain. 

The  nasal  bones,  when  affected,  exhibit  an  overlying  congested 
skin ;  pressure  on  the  bridge  is  responded  to  by  much  pain  ;  the 
lachrymal  secretions  are  affected,  and  not  unfrequently,  because  of 
the  congestion  in  the  ductus  ad  nasum,  run  over  the  cheek.  The 
turbinated  bones,  when  they  are  the  seat  of  the  inflammation,  yield 
a  soreness  to  the  lateral  aspects  of  the  canal,  and  respond  quickly  to 
pressure  exerted  thereon. 

Whichever  of  these  bones  may  be  affected,  its  history,  so  far  as 
ozaena  is  concerned,  is  the  same  in  signification.  If  the  inflamma- 
tion is  not  arrested,  necrosis  or  caries,  partial  or  complete,  results. 
Soon  a  discharge  makes  its  appearance,  disgustingly  foul  if  the  case 
is  one  of  necrosis,  and  more  or  less  offensive,  and  mixed  with  osseous 
particles,  if  it  is  caries. 

Anti-venereal  treatment  is  a  treatment  of  building  up.  You  cannot 
hope  to  arrest  syphilis  in  any  other  wa}^  when  it  has  passed  to  its 
tertiary  manifestations.  Limit  and  circumscribe  the  local  inflamma- 
tion as  much  as  you  can ;  and  to  do  this  you  will  generally  find  that 
stimulants  act  a  better  part  than  depressants.  An  excellent  medica- 
ment is  a  combination  of  iron,  iodine,  quinine,  and  glycerine: 

R. — Tincturse  ferri  chloridi,  5j ; 
Quiniae  sulphatis,  gr.  xxv  ; 
Tincturae  iodinii, 
Glyceringe,  aa  ^j  ; 
Aquas,  siv.     M. 
Sig. — Inject,  or  brush  over  and  about  the  parts,  three  times  a  day 

Give  iron  and  quinia  internally.  It  is  scarcely  probable  that  a 
patient  having  syphilitic  necrosis  needs  a  mercurial  course  ;  indeed, 
it  is  much  more  likelj^that  he  has  already  been  so  over-drugged  with 
this  medicine  that  his  trouble  is  mercurio-syphilitic,  rather  than 
syphilitic  alone.  Iodide  of  potassium  is  recommended  and  freely 
prescribed  in  these  tertiary  conditions;  it  may  be  given  in  doses  of 
from  ten  to  twenty  grains  dissolved  in  water  or  in  the  fluid  extract 
of  sarsaparilla.  But  good  rare  roast  beef,  poultry,  a  daily  glass 
of  malt  liquor,  boat-rowing,  wrestling,  horseback-riding,  systematic 
bathing,  these  are  the  reliable  means,  and  may  elevate  the  vital 
forces  to  an  ability  ^^er  vias  naturales  to  throw  off  the  disease.  It 
is  confessedly  hard  to  cure  syphilis  when  it  has  fully  taken  hold  of 
the  system  ;  and  when  it  inflames  a  bone,  particularly  a  small  one, 


OZ^NA.  655 

the  patient  is  lucky  if  he  escape  without  the  complete  destruction 
of  the  part. 

Necrosis,  partial  or  complete,  implies,  of  course,  the  existence  of 
a  sequestrum  ;  and  the  getting  away  of  this  dead  part  implies  very 
generally  the  cure  of  the  ozsena.  Particularly  is  this  the  case  when 
the  death  is  limited  to  the  single  bone  or  piece.  To  get  away  this 
piece  is,  then,  one  of  the  most  important  features  in  the  treatment. 
How  is  it  to  be  done  ?  Simply  wait  until  the  probe  reveals  that  it 
is  loose ;  if  it  may  not  be  taken  away  through  the  orifice  of  the  sinus 
it  has  itself  created,  we  have  only  to  enlarge  in  any  convenient  man- 
ner such  sinus,  and  then  lift  the  piece  away.  If,  after  the  removal  of 
such  dead  bone,  we  find  the  discharge  continuing,  but  modified  as 
to  character  and  odor,  we  infer  the  necessity  for  stimulation,  and 
use  iodine,  or  iodine  and  iron,  or  the  combination  with  tannin 
and  glycerine,  as  seems  to  be  indicated.  It  may  be,  however,  that 
neither  the  discharge  nor  the  odor  decreases ;  in  such  cases  we  are 
seldom  wrong  in  inferring  that  more  dead  or  dying  bone  is  in  the 
wound,  and  the  treatment  first  employed  is  to  be  renewed.  When 
tertiary  syphilis  has  associated  with  it  severe  nocturnal  pains,  great 
relief  is  frequently  secured  from  the  administration  of  the  iodide  of 
potassium,  particularly  if  combined  with  minute  doses  of  phosphorus, 
— say  five  drops  of  the  diluted  phosphoric  acid  as  a  dose ;  it  is  to  be 
remembered,  however,  that,  because  of  the  relationship  of  the  potash 
with  the  mucous  membranes,  in  many  persons  even  very  small  doses 
will  excite  much  irritability  in  the  air-passages,  thus  seeming  to  in- 
crease instead  of  allaying  the  trouble.  With  such  patients  we  must 
diminish  the  dose  of  the  iodide  j)ro  re  nata. 

Bromide  of  potassiurn  is  now  frequently  employed  to  procure  rest 
and  tranquillity.  It  is  commonly  prescribed  in  doses  of  ten  grains  ; 
but  forty  or  fifty  will  be  found  the  better  dose.  It  is  best  given  in 
a  little  water  just  as  the  patient  is  about  to  get  into  bed. 

Lodgment  and  Retention  of  Foreign  Bodies. — In  the  use  of  cotton 
or  sponge  about  the  uares,  care  is  to  be  taken  that  the  pellets  do  not 
escape  attention  and  remain  lodged  in  the  passages.  Some  of  the 
most  offensive  and  resisting  discharges  occasionally  have  their  cause 
in  this  direction.  Rhinolites — calculi  varying  in  size  from  that  of  a 
pea  to  that  of  a  pigeon's  Q^g — sometimes  form  in  the  canals,  and,  by 
inducing  ulceration  and  collecting  detritus,  become  the  source  of  ozsena. 
Peas,  rags,  buttons,  and  sundry  other  articles  are  not  unfrequently 
found  in  the  nares,  thrust  there  by  children  of  experimental  procliv- 
ities :  any  of  which  may,  of  course,  become  a  source  of  offense. 


656  ORAL  DISEASES  AND  SURGERY. 

The  removal  of  foreign  bodies  from  the  nares  is  always  to  be  ef- 
fected as  speedily  and  with  as  little  injury  to  the  parts  as  possible. 
A  plan  that  may  first  be  tried  is  to  place  the  patient  in  a  strong  light 
and  search  the  parts  with  very  delicate  forceps :  if  the  body  can  be 
seen,  it  may  thus  generally  be  removed.  Another  plan  consists  in 
giving  a  pinch  of  snuff  and  compressing  the  unobstructed  nostril; 
the  effort  of  sneezing  will  not  unfrequently  throw  the  body  a  con- 
siderable distance.  Still  another  plan  is  to  compress  the  unobstructed 
nostril  and  blow  into  the  mouth,  thus  forcing  it  out.  An  annealed 
wire,  bent  into  the  form  of  a  loop  and  passed  over  the  body,  is  very 
frequently  employed  with  satisfactory  success ;  a  flexible,  blunt, 
double  hook  is  also  used  with  advantage.  The  syringe  is  sometimes 
found  beneficial,  the  obstruction  being  washed  back  into  the  throat. 

The  convenience  of  the  douche  bath  in  ozasna  is  found  very  great. 
Thudichura's  apparatus*  highly  commends  itself  in  such  direction. 
Another  instrument  of  great  service  is  the  rubber  bulb  atomizer  : 
this  is  used  by  the  patient  without  effort  or  trouble  of  any  kind, 
and  carries  the  spray  to  every  part  of  the  nostril.  This  little  instru- 
ment may  be  charged  with  a  solution  of  permanganate  of  potash  or 
with  chlorine-water,  and  kept  about  the  person  ready  for  use  at  any 
required  moment.  In  cases  which  emit  much  fetor,  its  employment 
will  avoid  many  moments  of  mortification. 

Syphilitic  coryzain  infants,  characterized  by  snuffling  and  difficulty 
in  holding  the  breast,  is  not  unfrequently  associated  with  offensive 
discharge.  Here  the  excessive  delicacy  of  the  affected  membrane 
is  not  to  be  overlooked.  While  it  is  a  necessity  to  keep  the  parts 
well  cleansed,  it  is  not  permissible  to  employ  any  but  the  gentlest 
means.  Borax-water  associated  with  a  little  glycerine  is  a  nice 
preparation,  or  a  weak  solution  of  the  phenate  of  soda  may  most 
satisfactorily  be  used.  Fissures  of  the  membrane  may  be  touched 
with  dilute  chloride  of  zinc,  or  with  iodine  ointment  made  very 
weak. 

*"Some  j'ears  ago  it  was  discovered  by  Professor  "Weber,  of  Halle,  that 
when  one  side  of  the  nasal  cavity  is  entirely  filled  through  one  nostril  with 
fluid  by  hydrostatic  pressure,  while  the  patient  is  breathing  through  the 
mouth,  the  soft  palate  completely  closes  the  choana;,  and  does  not  permit  any 
fluid  to  pass  into  the  pharynx,  while  the  fluid  easily  passes  into  the  other 
cavity,  mostly  round  and  over  the  posterior  edge  of  the  septum  narium,  and 
escapes  from  the  other  open  nostril,  after  having  touched  every  part  of  the 
first  half  of  the  cavity  of  the  nose,  and  a  great  part — certainly  the  lower  and 
median  canals — of  the  second  half." — Thudichum  :  Polypus  in  the  Nose,  and 
Ozxna. 


OZ^NA.  657 

The  employment  of  the  rhinoscope  iu  rhinorrhoea  or  oz^na  is 
to  be  commended  as  of  great  value  in  making  a  diagnosis.  Ante- 
rior rhinoscopy  is  performed  most  simply  by  using  two  delicate 
ivory  spatulas  and  placing  the  patient  in  the  full  sunlight.  Or, 
placing  his  back  to  a  bright  gas-flame,  a  stream  of  light  is  thrown 
up  the  nostril  by  means  of  a  reflector.  A  mode  of  anterior  illumi- 
nation frequently  employed  by  the  author  consists  in  extending  the 
ala,  and  passing  the  light  through  a  silvered  speculum. 

The  nasal  speculum  of  Metz  differs  from  the  ivory  blades  in  being 
made  of  highly-polished  metal.  A  speculum  known  as  Duplay's 
anterior  is  the  analogue  of  the  common  bivalve  vaginal  instrument, 
the  valves  being  separated  by  means  of  a  screw. 

Posterior  rhinoscopy  is  not  so  easy  and  simple  of  accomplishment : 
indeed,  in  many  cases  it  is  impossible  to  reap  any  benefit  from  it. 
An  instrument  devised  by  Dr.  Limrock  is  highly  lauded  by  many 
for  its  capability  in  this  direction,  being  provided  with  a  movable 
spatula,  which  governs  the  movements  of  the  uvula.  A  modifica- 
tion of  the  instrument  by  Duplay  is  also  before  the  profession. 
This  consists  of  a  glass  and  delicate  hook  attached  to  associated 
shanks,  the  two  separating  as  do  the  blades  of  a  pair  of  scissors. 
The  author  frequently  practices  posterior  rhinoscopy  by  placing  the 
patient,  with  widely-opened  mouth,  in  the  direct  rays  of  the  sun,  using 
the  square  glass,  and  controlling  the  uvula  with  a  scalpel-handle.* 

*  A  most  instructive  clinical  lecture  on  Rhinoscopy,  by  Dr.  Harrison  Allen, 
will  be  found  published  in  the  Philadelphia  Medical  Titnes  for  August,  1872, 
to  which  the  reader  is  referred. 


42 


CHAPTER    XXXIII. 

THE    ANTRUM    OF    HIGHMORE,  AND   ITS   DISEASES. 

Many  years  spent  in  a  practice  which  should  have  afforded  every 
opportunity  for  observation,  as  well  as  a  scope  of  view  which 
necessarily  offers  to  one  who  is  a  frequent  visitor  at  hospitals  and 
clinics,  combine  to  impress  me  with  the  truthfulness  and  propriety 
of  the  conclusion,  that  the  diseases  of  the  antrum  are,  for  the  most 
part,  simple  in  character,  easy  of  diagnosis,  and,  as  a  rule,  not  at  all 
difficult  of  treatment.  Indeed,  I  have  not  unfrequently  thought  that, 
for  the  "purpose  of  general  study,  one  would  not  be  entirely  without 
justification  in  asserting  that  there  are  but  two  sources  of  trouble 
to  be  found  in  this  cavity  :  the  first,  and  prominent,  being  lesions 
secondary  to  the  diseases  of  the  teeth  ;  the  second,  the  troubles 
common  to  mucous  membranes,  wherever  situated. 

Certain  I  am,  at  any  rate,  that,  without  fear  of  successful  contra- 
diction, I  may  assert  that  the  gr.eat  majority  emanate  from  the  first 
of  these  directions  ;  while  the  atonic  conditions,  represented  by  the 
dropsies,  the  puruloid  secretions,  the  mucous  ejigorgements,  and  the 
ulcerations,  are  in  no  wise  different  from  the  ordinary  mucoid  affec- 
tions, except  as  modifications  may  be  made  by  situation,  the  last 
being  conclusively  proven,  I  think,  by  the  fact  that  what  is  the  cure 
of  the  one  is  the  cure  of  the  other. 

While  thus  asserting,  however,  that  in  these  two  directions  lie 
the  chief  sources  of  trouble,  I  would  not  by  any  means  be  understood 
as  implying  that  the  subject  is  unworthy  of  investigation  outside  of 
such  considerations :  on  the  contrary,  I  am  bound  to  confess  that  I 
find  recorded  more  than  one  description  of  diseases  of  the  cavity, 
which  to  me,  at  least,  are  as  anomalous  in  principle  as  they  are  in 
description,  and  which  I  can  only  explain  either  on  the  ungenerous 
supposition  that  the  authors  must  have  drawn  somewhat  on  their 
descriptive  powers,  or  else  that  the  antrum  has  some  of  the  strangest 
anomalies. 

Again,  as   a   class   coming   between  these    uncommon    and   the 
common  affections,  it  follows,  not  at  all  indirectly,  that  there  exist 
(658) 


ANTRUM  OF  HIGHMOKE,  AND   ITS  DISEASES.     659 

sequelae  of  certain  of  the  exanthemata  which  have  a  special  and 
peculiar  affinity  for  this  cavity ;  while,  in  syphilis,  I  have  seen  the 
very  first  event  in  the  secondary  train  exhibiting  itself  in  a  dis- 
turbance of  this  sinus.  That  this  latter,  however,  is  rare,  I  well 
know  from  observation  extending  ^ver  a  great  number  of  cases ; 
indeed,  syphilitic  troubles  of  the  antrum  are  so  infrequent  even  in 
the  tertiary  stage  of  that  affection,  that  observation  will  lead  to  the 
inference  that  the  cavity  never  takes  on  the  disease  unless  when,  from 
continuity  of  structure,  it  has  the  trouble  absolutely  forced  upon  it, 
as  it  were,  either  from  its  relationship  with  the  hard  palate  in  the 
oral  direction,  or  with  the  turbinated  bones  in  the  nasal ;  for,  while 
the  practitioner  will  surely  hear  complaints,  yet,  if  he  investigates 
the  cause  of  trouble,  he  will  find,  as  I  so  often  have  found,  that  mer- 
curial inflammation  of  periodonteal  membranes  is  the  source  of  offense, 
rather  than  the  specific  condition.  Clumsily  performed  surgical 
operations  are  also  the  occasional  causes  of  morbid  conditions  being 
set  up  in  the  cavity,  which,  when  existing,  would  of  course  be  so 
evident  as  to  force  the  consideration  of  them  upon  the  attention, — 
the  most  common  of  these  being  the  breaking  of  the  fangs  of  teeth 
in  attempts  to  extract  these  organs. 

With  these  preliminary  remarks,  we  pass  to  a  consideration  of 
the  premised  principal  cause  of  antral  trouble, — diseased  teeth. 

In  the  chapter  treating  on  "  Anomalies  of  Dentition,"  attention 
w^as  directed  to  the. close  relationship  of  the  fangs  of  several  of  the 
teeth  with  the  floor  of  the  antrum,  and  to  the  fact  that  it  was  not 
unfrequent  to  find  these  fangs  —  particularly  the  palatine  of  the 
second  molar — penetrating  the  sinus,  thus  associating  their  mem- 
branes, and  furnishing  a  continuity  of  structure. 

In  the  same  chapter  attention  was  also  called  to  such  diseases 
and  conditions  of  the  alveolar  border  as  were  apt  secondarily  to 
affect  the  antrum  ;  means  of  diagnosis  and  treatment  being  sug- 
ge.sted.  The  reader  who  may  feel  sufficient  interest  in  the  subject 
will  do  well  to  review  the  chapter  alluded  to,  ])efore  proceeding  to 
the  consideration  of  the  clinical  cases  presented,  and  which,  I 
think,  will  sufficiently  illustrate  this  department  of  diseases  of  the 
antrum. 

Case  I. — Indolent  Tumor  on  the  Bight  Cheek. —  A  woman  had 
an  indolent  tumor  on  the  right  cheek,  about  the  size  of  a  pigeon's 
eg^,  occasioning  much  disfigurement,  but  altering  the  color  of  the 
skin  very  slightly.     The  patient  had  often  suffered  violent  tooth- 


660  ORAL  DISEASES  AND   SURGERY. 

ache  on  this  side,  aad,  though  young,  had  few  teeth  now  remaining, 
and  these  all  carious ;  otherwise  she  was  in  very  good  health. 
The  tumor  was  prominent  toward  the  cheek,  palate,  and  nostril, 
yielded  on  pressure,  and  gave  a  slight  noise  as  it  returned  to  its 
position. 

These  symptoms  caused  the  practitioner  to  suspect  the  existence 
of  some  fluid,  which  it  was  necessary  to  evacuate  and  follow  with 
suitable  injections.  For  this  purpose,  the  cheek  was  drawn  aside, 
and  an  incision  made  into  the  bone  above  the  gum,  with  a  bistoury, 
enlarging  it  before  and  backward,  till  a  sufficient  opening  was  ob- 
tained, from  which  escaped  an  inodorous  mucous  fluid.  The  bone 
was  at  no  point  denuded  of  its  periosteum.  The  wound  was  dressed 
with  a  pledget  of  lint  saturated  with  spirits  of  wine,  and  the  next 
day  the  patient  was  better.  On  the  third  day  she  was  feverish,  the 
sinus  was  swollen  and  painful,  and  the  discharge  acrid  and  fetid. 
These  symptoms  were  controlled  by  proper  remedies,  and,  after 
twenty-four  days,  the  walls  of  the  sinus  were  nearly  restored  to 
their  normal  condition. 

The  canine  tooth  of  this  side  being  very  obliquely  situated,  it  was 
thought  proper  to  extract  it,  and  thereupon  followed  an  escape, 
through  its  socket,  of  fluid  contained  in  the  sinus,  though  the  tooth 
itself  seemed  perfectly  sound.  Through  this  orifice  injections  were 
made.  The  opening  made  in  the  external  wall  healed  promptly, 
without  any  exfoliation  ;  in  six  months  the  tumor  entirely  disap- 
peared, and  the  patient  was  cured.  (From  Baron  Haller's  "  Collec- 
tion of  Medico-Chirurgical  Theses.") 

The  translator  of  the  above  case,  in  commenting  upon  the  treat- 
ment, pointedly  remarks,  "  One  cannot  fail  to  see  the  uncertainty, 
not  to  say  obscurity,  of  the  treatment  here  adopted.  Though  all 
the  teeth  were  carious,  and  their  extraction  was  plainly  indicated, 
an  incision  in  the  external  wall  of  the  antrum,  or,  more  correctly,  its 
destruction,  was  determined  upon.  Tlie  result  we  see  in  the  symp- 
toms which  supervened  on  the  third  day,  which  were,  perhaps, 
hastened  by  the  spirits  of  wine.  We  have  here  a  canine  tooth  quite 
displaced  and  involved  in  the  tumor;  yet  it  was  long  before  the  idea 
of  its  extraction  occurred,  though  the  subsequent  discharge,  through 
its  socket,  proved  how  advisable  it  would  have  been  at  the  com- 
mencement of  the  treatment.  In  this  way  the  time  of  cure  might 
have  been  shortened  by  half." 

Case  II. — Distention  ivith  Softening  of  the  External  Walls  of 
the  Sinus. — "In ,"  says  this  same  surgeon,  "I  was  consulted  in 


ANTRUM    OF  HIGHMORE,   AND   ITS  DISEASES.     661 

the  case  of  a  large  tumor  of  the  right  cheek.  The  external  wall 
was  much  distended  and  softened,  and  yielded  to  pressure,  upon 
the  removal  of  which  it  gave  a  sound  resembling  the  crushing  of 
an  egg-shell.  The  nose  was  turned  to  one  side, — the  nostril  was 
obstructed, — yet  the  patient  suffered  no  pain,  and  the  skin,  though 
distended,  preserved  its  natural  color.  On  examination  of  the 
mouth,  I  found  that  the  crowns  of  the  bicuspidati  and  molars  were 
destroyed  by  caries,  which  induced  me  to  advise  the  extraction  of 
their  persistent  fangs  ;  the  patient  consenting,  this  was  immedi- 
ately done.  The  shock  occasioned  by  the  extraction  of  each  of  the 
fangs,  caused  a  portion  of  fluid  to  escape  from  the  sinus  through  the 
natural  opening:  it  was  thin,  reddish,  saline,  and  inodorous,  and, 
in  all,  about  three  spoonfuls.  The  tumor  could  now  be  made  to  dis- 
appear b}'  pressure,  but  would  again  return  to  its  full  size.  Pressure 
caused  no  escape  of  fluid  through  the  nasal,  and  but  slight  through 
the  alveolar,  opening,  which  was  at  the  bottom  of  the  first  molar 
socket,  and  large  enough  to  admit  the  finger. 

"  The  interna]  membrane  of  the  sinus  was  entire,  except  at  the 
alveolar  opening  :  through  this  I  made  injections  of  warm  water, 
strengthened  with  a  little  alcoholic  vulnerary  fluid.  The  next  day 
I  injected  the  sinus  repeatedly  with  a  decoction  of  agrimony*  and 
honey  of  roses,  meanwhile  not  neglecting  external  compres.sion.  In 
fifteen  days  the  parts  returned  to  their  natural  condition,  all  crepita- 
tion of  the  bone  ceased,  and  the  discharge  was  very  slight.  I  now 
had  recourse  to  stimulating  solutions.  On  the  second  day  the  dis- 
charge had  ceased,  and  the  alveolar  opening  was  reduced  to  a  mere 
fissure,  and  in  a  month  from  the  extraction  of  the  teeth  the  patient 
was  fully  restored." 

Case  III. — Periodonteal  Abscess  affecting  the  Antrum. — A  patient 
was  brought  to  me  who,  for  more  than  three  months,  had  suffered 
with  a  tumor  like  the  above,  on  the  right  side.  The  maxillary 
cavity  was  distended  to  a  level  with  the  orbital  margin  ;  the  nose 
was  turned  to  one  side,  and  the  vault  of  the  palate  was  remarkably 
prominent.  I  removed  the  fangs  of  the  first  two  molars,  the  crowns 
of  which  had  been  destroyed  by  caries,  and  which  I  believed  to  be 
the  immediate  cause  of  the  disease.     I  then  enlarged  the  opening  at 

*  A  mild  tonic  and  astringent.  An  injection  of  more  character  would  be 
as  follows: 

R- — Grlycerina3,  5J  ; 

Tincturffi  opii  camphorataj,  5ij  ; 
Aquae  Colonise,  ,^iv.     M. 


662  ORAL  DISEASES  AND  SURGERY. 

the  bottom  of  one  of  the  sockets,  through  which  escaped  a  large 
quantity  of  a  serous  inodorous  fluid.  Pressure  upon  the  palate  and 
external  wall  caused  its  escape  through  both  the  alveolar  and  the 
nasal  opening:  this  compression,  together  with  suitable  injections, 
soon  terminated  the  disease. 

The  teeth  on  the  left  side  being  in  a  similar  condition,  their  re- 
moval was  urged  ;  but  to  this  the  patient  would  not  consent.  In 
three  months  she  came  to  me  with  a  precisely  similar  swelling  of 
this  side,  which,  having  the  same  cause,  I  cured  in  the  same 
manner. 

Case  IV. — Abscess  of  the  Antrum  caused  by  a  Tooth. — The  fol- 
lowing very  interesting  and  instructive  case  is  from  the  practice  of 
Dr.  J.  D.  White,  and  was  reported  for  the  Dental  Cosmos  by  his 
son,  Horace  Meredith  White,  M.D.  : 

"Mr.  S.,  aged  twenty  years,  light  complexion,  peculiar  whiteness 
of  the  skin, — a  characteristic  of  the  family, — had  been  complaining 
for  some  time  of  a  fetid  discharge  from  the  right  nostril ;  of  heat, 
and  a  sense  of  tension,  in  the  right  superior  maxilla. 

"  He  applied  to  his  physician,  who  gave  him  a  wash,  with  the 
belief  that  the  parts  would  speedily  return  to  their  normal  condition, 
he  supposing  the  affection  to  be  merely  an  increased  discharge  de- 
pending on  a  slight  local  hyperemia,  the  result,  perhaps,  of  the  bad 
state  of  the  weather  at  the  time.  The  parts,  however,  did  not  re- 
cover; the  discharge  became  much  more  fetid,  and  evidently  was 
principally  composed  of  unhealthy  pus,  though  it  was  not  as  copious 
as  it  had  been  previously  ;  the  pain  was  not  severe,  but  the  heat  of 
the  parts  more  elevated,  and  the  sense  of  tension  increased.  The 
patient  was  irritable  and  pale  ;  the  heat  of  the  body  was  rather 
above  the  average  temperature.  This  was  the  condition  of  tlie  patient 
when  he  came  under  the  care  of  Dr.  W. 

"  Upon  examining  the  anterior  naris,  nothing  could  be  discovered 
to  account  for  the  discharge  ;  tlie  mucous  membrane  being  a  little 
inflamed,  but  not  sufficient  to  occasion  it.  A  diseased  state  of  the 
antrum  was  suspected,  and  the  mouth  was  examined  to  ascertain  if 
a  diseased  tooth  could  be  the  cause.  The  second  molar,  upper  jaw, 
right  side,  was  unsound.  .  Part  of  the  crown  was  decayed  away ;  the 
bulbous  portion  of  the  nerve,  and  the  filaments  of  the  buccal  roots, 
were  dead,  but  that  part  in  tlie  palatine  root  was  living,  and  occa- 
sioned the  patient  pain.  A  little  arsenical  paste  was  applied  to  de- 
stroy it.  No  sign  of  alveolar  abscess  was  present  in  it  ov  any  other 
tooth.     The  next  day  the  nerve  in  the  palatine  fang  was  removed 


ANTRUM   OF  HIGHMORE,   AND   ITS  DISEASES.     663 

without  trouble  ;  a  careful  inspection  was  now  made,  and  important 
information  was  received.  Upon  examining  the  right  nostril  with 
a  speculum,  a  little  pus  was  seen  in  the  middle  meatus.  The  patient 
was  requested  to  incline  the  head  toward  the  left  side ;  he  did  so, 
and,  upon  looking  at  the  parts  again,  a  large  amount  of  pus  was 
found.  This,  together  with  the  facts  stated  already  in  this  paper, 
and  that  there  was  no  other  assignable  cause  of  the  discharge,  was 
deemed  sufficient  to  establish  the  diagnosis, — abscess  of  the  antrum, 
caused  probably  by  the  unsound  second  molar  tooth. 

"  Extraction  was  advised  and  submitted  to.  Upon  the  removal 
of  the  tooth  no  pus  escaped.  A  probe  was  introduced  into  the  alve- 
olus previously  occupied  by  one  of  the  buccal  roots,  and  readily 
passed  on  into  the  antrum  ;  pus  now  followed  the  withdrawal  of  the 
instrument. 

"The  cure  was  completed  on  general  principles." 

Dr.  White  concludes  the  description  of  his  case  by  remarking  a 
coincidence  which  it  will  not  be  at  all  amiss  to  repeat  here, — a  coin- 
cidence which  must  have  been  very  alarming  to  the  patient.  The 
gentleman  had  repeatedly  visited  a  horse  belonging  to  his  father, 
which  had  a  profuse  discharge  from  the  nose,  thought  to  be  glanders. 
The  date  of  the  horse's  malady  was  prior  to  that  of  the  patient, 
and,  of  course,  the  inference  as  to  infection  was  a  very  natural  one. 

Dropay  of  the  Antrum. — This,  which  is  only  another  name  for 
mucous  engorgement,  is  not  uufrequently,  as  I  have  had  occasion  to 
observe,  the  result  of  a  reflected  chronic  periodonteal  inflammation. 
In  such  cases,  we  have  the  analogue  of  similar  inflammation  in  the 
cavity  of  the  mouth  :  the  membrane  becomes  puffy  and  thickened, 
the  mucous  secretions  become  inspissated,  and  the  natural  opening  of 
the  sinus  (simply  through  this  thickening  of  the  mucous  membranes, 
the  folds  of  which  are  the  natural  outlet  of  the  cavity)  becomes  ob- 
literated. All  egress  being  closed,  the  result  is  not  difficult  to  sur- 
mise :  if  there  should  not  occur  atresia  of  the  occluding  membranes, 
and  no  correct  surgical  assistance  is  afforded,  there  must,  of  course, 
result  either  the  gradual  attenuation  of  the  weakest  portion  of  the 
parietes  of  the  cavity,  or  the  setting  up  of  active  and  severe  inflam- 
mation. If,  on  the  contrary,  the  natural  outlet  has  a  partial  restora- 
tion, it  is  not  at  all  unlikely  that  a  troublesome  and,  if  misunder- 
stood, tedious  and  unmanageable  puruloid  discharge  will  ensue: 
this  being  the  result  of  a  continuance  of  the  cause  of  trouble. 
Recalling  illustrative  examples  from  my  own  practice,  I  remember 


664  ORAL  DISEASES  AND  SURGERY. 

particularly  the  case  of  a  child  who,  previously  to  coming  under  care, 
had  been  treated  nearl}'  two  years  for  the  occasional  discharge  of 
muco-purulent  matter  from  the  left  nostril ;  the  child  was  of  bad 
temperament,  being  a  cross  of  the  bilio-lymphatic.  This  patient  I 
had  the  satisfaction  of  relieving  in  a  single  week,  the  treatment  being 
wholly  directed  to  the  dental  arch,  if  I  may  except  a  course  of  salt 
sheet-baths, — continued  long  after  the  local  cure,  and  which  had  been 
directed  in  consideration  of  the  relaxed  condition  of  her  general 
system. 

The  relation  of  temperament  and  conditions  is  to  be  closely  con- 
sidered in  connection  with  these  diseases  of  the  antrum :  it  is,  of 
course,  far  from  being  every  one  who  is  troubled  with  a  bad  tooth, 
the  fangs  of  which  penetrate  the  cavity,  who  has  secondary  disease 
as  the  result.  I  have  just  now  under  treatment  a  patient  suffering 
from  necrosis  of  the  whole  roof  of  the  mouth,  the  result  of  a  syphi- 
litic cachexia,  the  exciting  cause  of  the  local  trouble  being  an  incisor 
tooth  anomalously  developed.  This  tooth,  the  extreme  point  of  which 
presented  just  back  of  the  incisive  foramen,  had  been  mistaken  by  a 
practitioner  for  the  point  of  a  sequestrum,  and,  being  worked, and 
cut  at,  periostitis  had  developed  ;  and  when  the  dead  bone,  which 
is  the  result,  is  ready  to  come  away,  I  am  sure  I  shall  find  both 
antra  exposed.* 

Without  such  predisposing  cause,  it  is  evident,  this  extensive  dis- 
ease would  never  have  been  excited.  It  is  the  same  as  in  every 
other  direction  of  surgical  practice:  one  man  receives  a  wound,  a 
cut  perhaps  on  the  face,  and  it  troubles  him  so  little  that  he  scarcely 
stops  for  a  moment  to  examine  the  injury ;  another  receives  pre- 
cisely the  same  kind  of  a  wound,  and  in  a  week  is  dead  from 
erysipelas. 

A  purulent  condition  of  the  secretions  of  the  antrum  may  be 
viewed  as  one  would  view  a  gonorrhoea  ;  indeed,  Mr.  Bell,  the 
English  author,  describes  the  conditions  as  being  similar,  "  both 
diseases,"  he  says,  "  consisting  equally  of  an  altered  secretion, — in 
the  one,  of  the  pituitary  membrane,  and  in  the  other,  of  the  muscular 
lining  of  the  urethra,  which  in  neither  instance  possesses  any  of 
the  characteristics  of  abscegs,  though  the  matter  in  both  is  purulent." 

Certainly,  if  we  allow  for  some  differences,  as  influenced  by  cause 
and  location,  the  description  of  the  one  would  very  well  answer  as 

*  This  proved  to  be  the  case,  the  lost  process  being  now  replaced  by  an 
obturator.     For  the  making  of  such  an  instrument,  see  "  Palatine  Defects.'' 


ANTRUM  OF  HIGHMORE,  AND   ITS  DISEASES.     665 

the  description  of  the  other.  In  both  we  have  the  same  perverted 
secretion,  the  same  molecular  change,  the  same  sthenic  and  asthenic 
modifications. 

As  a  gonorrhoeal  discharge  is  always  preceded  by  certain  inflam- 
matory conditions,  and  as,  after  the  subsidence  of  the  acute  attack, 
the  discharge  may  long  continue  profuse,  or,  on  the  contrary,  may 
decline  to  a  scarcely  perceptible  minimum,  so,  in  antral  puijulency, 
must  we  have  the  associated  inflammation,  and  may  have  the  pro- 
fuse or  limited  secretion. 

In  antral  diseases,  however,  as  may  be  readily  inferred,  very  much 
depends  on  the  nature  and  associations  of  the  secretion.  A  profuse' 
discharge,  with  closure  of  the  orifice  of  the  cavity,  must  necessarily 
entail  the  most  untoward  consequences  :  the  walls  of  the  cavity  will 
attenuate  until  (unless  surgically  relieved)  the  weakest  point  will 
give  way,  the  rupture  being  most  apt  to  occur  either  within  the 
orljit  or  the  mouth.  Xot  unfrequently,  however,  this  weakest  por- 
tion seems  to  be  the  canine  fossa;  the  opening  has  also  occurred  at 
the  tuberosity.  My  own  experience  would  lead  to  the  inference 
that  the  hard  palate  is  by  far  the  most  common  point  at  which  the 
matter  seeks  egress.  You  will  see  a  tumor  bulging  out  from  one 
side  of  the  mesial  line,  and  which  advances  more  or  less  rapidly, 
until  fluctuation  becomes  very  distinct.  A  sign  diagnostic  of  this 
class  of  tumors  is,  that  its  internal  boundary  is  apt  to  be  quite 
abrupt,  and  does  not  pass  the  line  midway  to  the  mesial  division. 
The  establishment  of  a  fistula  relieves  it  at  once  of  the  sense  of 
distention,  and,  if  it  has  formed  in  a  convenient  place,  as  within  the 
mouth,  the  patient  may  feel  disposed  to  congratulate  himself  on 
having  come  to  a  sufficient  cure.  Unfortunately,  however,  in  the 
majority  of  cases,  this  satisfaction  is  of  short  continuance  ;  for,  inde- 
pendently of  the  fact  that  the  disease  at  once  takes  on  the  chronic 
form,  making  the  sufferer  an  object  of  disgust  to  those  with  whom 
he  is  brought  into  immediate  contact, — the  fetor  of  the  discharge, 
under  some  circumstances,  being  really  unbearable, — the  undue  re- 
tention of  the  secretion  within  the  cavity  is  a  source  of  such  irrita- 
tion to  the  parts  that  not  unfrequently  the  most  serious  lesions 
result.  In  some  instances — happily,  rare — all  the  bones  of  the  face 
are  destroyed. 

The  causes  influencing  retention  of  these  secretions  are  twofold : 
First,  the  external  wound  is  apt  to  heal,  and  to  continue  impervious 
until  an  increase  of  the  secretion  induces  sufficient  pressure  to  cause 


666  ORAL  DISEASES  AND  SURGERY. 

its  absorption,  as  in  any  case  of  abscess.     In  tlie  second  place,  the 
passage  is  blocked  up  by  flocculi  within  the  cavity. 

Puruloid  secretion  in  the  antrum  may,  from  the  onset,  be  of  so 
limited  a  character  that,  like  secretions  in  certain  of  the  ovarian 
cysts,  years  may  pass  before  marked  inconvenience  results.  I  am 
acquainted  with  a  case,  that  of  Mr.  C,  late  an  eminent  merchant  of 
this  city,  in  whom,  after  five  years  of  great  mental  and  physical 
suffering,  a  disease  of  the  antrum,  supposed  to  be  malignant,  was 
found  to  be  nothing  but  simple  muco-puruloid  engorgement  depend- 
ino-  upon  a  dead  tooth.  In  this  case  the  trouble  had  commenced 
with  a  feeling  of  heaviness  and  oppression  in  the  body  of  the  jaw  ; 
the  parts  had  gradually  enlarged  until  finally  there  was  distention 
of  the  cheek  to  the  size  of  a  large  fist,  the  eye  being  thrown  entirely 
out  of  position  from  the  rising  of  the  roof  of  the  antrum.  Much 
treatment  had  been  given  the  case,  without  the  slightest  benefit 
accruing.  Xo  attention,  however,  had  been  directed  to  the  dental 
arch, — the  teeth,  although  the  patient  was  sixty  years  of  age,  being 
apparently  ia  the  most  perfect  condition. 

The  result  of  this  case  was  the  diagnosis,  on  the  part  of  a  surgeon 
to  whom  he  finally  applied,  of  a  dead  nerve  in  one  of  the  bicuspid 
teeth.  The  organ,  although  as  healthy-looking  as  any  of  its  fellows, 
responded  to  the  stroke  of  an  instrument  in  the  manner  described 
in  the  chapter  on  alveolar  abscess;  this  tooth  was  extracted,  and  in 
six  months  the  health  of  the  patient  was  perfectly  restored. 

A  circumstance  connected  with  the  extraction  of  the  tooth  in  this 
case  offers  an  example  of  practice  of  which  it  is  well  not  to  lose 
sight.  The  practitioner  who  related  to  me  the  circumstance,  informed 
me  that  he  fexpected  to  find  associated  with  the  tooth-fang  a  pyo- 
genic membrane,  and  to  have  the  extraction  followed  by  a  gush  of 
pus,  in  both  of  which  expectations,  however,  he  was  disappointed. 
The  fang  was  clean,  and  the  blood  which  followed  the  operation 
had  nothing  peculiar  about  it.  Xot  to  be  thus  balked,  he  passed  a 
probe  up  the  alveolus  of  the  extracted  tooth,  which,  meeting  a 
resisting  yet  yielding  body,  he  punctured  in  the  direction  of  the 
antrum  ;  the  withdrawal  was  followed  by  a  profuse  purulent  dis- 
charge. This  resisting  body  may  be  simply  flocculi,  as  alluded  to, 
or  it  may  be  the  mucous  membrane  proper  to  the  parts:  most  likely 
it  would  be  found  the  latter,  for  we  are  to  remember  that  it  is  not 
alveolar  or  antral  abscess  with  which,  in  these  cases,  we  are  deal- 
ing, but  simply  what  might  be  termed  a  mucitis,  and,  of  course,  a 
break  in  the  continuity  of  the  membrane  is  not  necessarily  to  be 


ANTRUM  OF  HIGH  MORE,  AND   ITS  DISEASES.     667 

looked  for.  The  practitioner,  in  this  case,  only  approximated  to  the 
exact  condition ;  he  thought,  evidently,  that  the  trouble  was  tooth- 
abscess  discharging  itself  into  the  sinus,  whereas  (while  the  treat- 
ment was  perfectly  adapted  to  the  requirements)  the  case  was  one 
of  simple  mucous  or  muco-puruloid  engorgement,  the  result  of  re- 
flected irritation. 

The  diagnosis  of  mucoid  and  puruloid  engorgement  of  the  antrum 
is,  as  a  rule,  not  difficult  to  make  out.  At  first  there  is  inflamma- 
tion, and  this,  as  suggested,  is  found  most  likely  to  have  origin 
about  the  teeth.  As  the  trouble  advances,  the  patient  begins  to 
complain  of  a  sense  of  heaviness  about  the  body  of  the  cheek.  If 
the  secretion  is  active,  there  will  be  much  pain,  sometimes  shai'p  in 
character,  but  more  frequently  heavy  and  unbearably  dull.  In  all 
chronic  periodonteal  inflammation  we  have  this  same  dull  pain,  but 
then  it  differs  from  the  pain  of  engorgement  in  being  confined  to  the 
alveolar  arch ;  in  this  latter  trouble  the  greatest  pain  is  found,  I 
think,  associated  with  the  floor  of  the  orbit,  which,  as  will  be  remem- 
bered, makes  the  roof  of  tlje  antrum.  At  length,  as  the  secretions 
accumulate,  the  parietes  of  the  cavity  begin  to  attenuate  and  expand. 
The  tumor  now  forming  may  be  distinguished  from  others, — first, 
by  the  history  of  the  case ;  second,  by  dryness  of  the  uaris  of  the 
affected  side,  the  result  of  the  closure  of  the  orifice  of  the  antrum  ; 
third,  by  the  gradual  and  regular  enlargement ;  fourth,  by  the  non- 
association  of  the  integuments  of  the  cheek;  and,  fifth,  by  the  fluc- 
tuation which  it  will  finally  yield.  V/ 

To  treat  successfully  such  a  trouble,  we  have  only  to  search  out 
the  source  of  offense,  and,  where  it  is  possible,  remove  it.  If  this 
should  prove  to  be  a  tooth,  we  may,  if  necessary,  secondarily  treat 
the  antrum  through  the  alveolus.  Where  the  trouble  is  thus  of 
strictly  local  origin,  we  shall  find  that  we  need  to  do  very  little 
more  than  employ  daily  some  stimulating  injection,  such  as  diluted 
tincture  of  iodine.  Where  the  acrid  character  of  the  retained  secre- 
tion has  provoked  degenerating  ulcers,  I  have  obtained  the  very 
happiest  effects  from  weak  injections  of  chloride  of  zinc. 

If,  on  the  contrary,  such  bad  conditions  of  the  antrum  be  associ- 
ated with  constitutional  causes,  I  need  not  suggest  that  such  causes 
must  have  our  attention.  In  these  latter  cases,  however,  where  the 
cure  promises  to  be  tardy,  we  may  give  to  a  patient  complete  relief, 
locally,  by  making  an  opening  into  the  cavity,  and  keeping  it  patu- 
lous by  means  of  a  cotton  teut;  this,  combined  with  the  daily  em- 


668  ORAL  DISEASES  AND   SURGERY. 

ployment  of  such  injections  as  may  seem  indicated,  will  be  found  to 
yield  decided  benefit. 

Concerning  abscess  proper  of  the  antrum,  I  think  it  may  be  set 
down  as  the  rarest  of  rare  diseases.  Bell  and  Bordenhave  each 
mention  a  case.  Abscesses,  described  so  frequently  as  occurring  in 
this  cavity,  will,  I  think,  commonly  be  found  to  have  their  origin  in 
the  alveolar  border,  and  if  treated  like  any  ordinary  case  of  alveolar 
abscess,  will  generally  at  once  succumb.  (See  Alveolar  Abscess,  and 
Anomalies  of  Dentition.) 

"While,"  says  Dr.  Richardson,  "we  cannot  trace  out  the  nature 
of  that  condition  of  the  blood  which  gives  rise  to  purulent  forma- 
tions, wc  are  informed  by  observation  of  the  external  conditions 
which  foster  it.  We  learn  that  the  pus-producing  disposition  is  an 
indication  of  deterioration  of  blood.  We  see  that  when  the  system 
is  enfeebled,  whether  by  diathesis  hereditarily  supplied,  ns  by  the 
strumous  diathesis, — whether  by  epidemic  influences,  or  whether  by 
deprivation  of  nitrogenous  food,  or  the  inhalation  of  had  air, — that 
under  these  circumstances  the  tendency  to  purulent  formations  in 
local  structures  is  marked,  and  that,  in  extreme  instances  of  the  kind 
named,  the  act  of  suppuration  may  take  its  absolute  origin  from 
blood  thus  depressed. 

"  Hence  we  have  reduced  almost  to  a  principle  in  medicine  the 
saying  that  suppurative  tendency  is  a  sign  of  an  impaired  or  vitiated 
nutrition.  Hence,  also,  we  reason  in  speculative  argument,  that 
pus  is  blood  transformed  into  a  lower  form  of  organization,  and  we 
adduce,  in  evidence  of  this  view,  that  the  purulent  fluid  is  incapable 
.of  organic  construction,  and  that  in  animals  in  which  the  respiration, 
the  circulation,  and  the  animal  temperature  are  more  than  ordinarily 
active,  the  formation  of  pus,  even  in  an  open  wound,  is  an  occur- 
rence almost  unknown." 

These  remarks,  from  the  lectures  of  Dr.  Richardson,  cannot  fail 
to  be  suggestive;  they  have  indeed  much  meaning;  but  I  must 
be  permitted  to  remind  the  student  reader,  at  least,  that  their  sig- 
nification is  limited.  Puruloid  conditions  are,  without  doubt,  and 
as  the  rule,  perhaps,  indications  of  asthenia;  but  it  would  be  very 
wrong  indeed  to  jump  from  such  data  to  the  conclusion  that  every 
puruloid  disease  requires  treatment  from  the  constitutional  stand- 
point; and  particularly  will  this  hold  good  as  the  diseases  of  the 
antrum  are  coucerned. 

All  diseases  should  be  treated  on  principle.     M.  Ricord,  as  many 


ANTBUM    OF  HIGHMORE,  AND   ITS  DISEASES.     669 

of  my  readers  will  remember,  has  a  favorite  prescription  for  gonor- 
rhceal  puruleacy,  which  runs  as  follows : 

B. — Pulveris  cubebse,  §vj; 

Ferri  carbonatis,  3iij.     M. 

Now,  anybody  can  understand  that  such  a  combination  would 
naturally  act  well  on  a  debilitated  system ;  and  I  should  sup- 
pose it  would  be  a  most  happy  prescription  for  half  the  roues  of 
Paris.  Where  applicable,  it  would  answer  as  well  for  the  puruloid 
antrum.  I  remember,  during  the  past  summer,  treating  a  gentleman 
for  a  gonorrhoeal  difficulty,  which  he  had  contracted  almost  immedi- 
ately after  my  getting  him  over  an  attack  of  syphilis.  I  treated  this 
patient  locally  over  six  weeks,  the  discharge  constantly  increasing 
in  quantity.  At  the  expiration  of  this  period  I  put  him  upon  co- 
paiba, tincture  of  iron,  and  quinia,  and  sent  him  to  the  seaside  for  a 
few  weeks.  The  discharge  at  once  began  to  diminish,  and  after  the 
eighth  day  disappeared  entirely.  A  success  of  this  kind  would  not, 
however,  lead  to  the  inference  that  every  man  afflicted  with  a  puru- 
lent discharge  should  be  treated  with  tonic  stimulants.  On  the 
contrary,  though  I  have  had  the  opportunity  of  prescribing  very  fre- 
quently for  this  condition, — gonorrhoea, — yet  it  is  seldom  that  indi- 
cations have  seemed  to  me  to  call  for  anything  more  than  a  strictly 
local  treatment;  at  any  rate,  I  have  generally  succeeded,  happily 
and  quickly,  in  getting  the  patients  over  their  trouble. 

On  a  previous  page  it  was  suggested  that  puruloid  conditions  of 
the  antrum  had  origin  chiefly  from  two  directions:  first,  from  dis- 
eased teeth  ;  second,  from  constitutional  disturbance,  manifesting 
itself  in  the  mucous  tissue.  It  was  also  desired  to  convey  the  infer- 
ence that  where  the  fault  was  markedly  in  the  first  of  these  direc- 
tions, the  practitioner  would  err  on  the  right  side  if,  in  his  first  con- 
sideration of  the  case,  he  should  incline  to  look  upon  the  tooth  only 
in  the  light  of  an  exciting  cause,  searching  farther  for  what  might 
be  a  predisposing  condition.  It  is,  however,  to  be  inferred  that 
lesions  of  the  cavity  may  exist,  and  yet  constitutional  conditions 
have  really  nothing  to  do  with  them,  and  in  the  treatment  need  not 
be  taken  into  the  account. 

As  a  line  in  practice,  however,  running  between  these  two  con- 
ditions, I  may  allude  to  the  fact  that  I  have  met  cases  where  infer- 
ence of  constitutional  association  seemed  most  marked,  and  yet  have 
soon  cured  my  patients  without  a  resort  to  other  than  local  treatment. 


< 

I 


670  ORAL  DISEASES  AND  SURGERY. 

These  are  the  kind  of  cases  in  which  the  medical  man  must  feel  his 
way:  if  he  be  an  observer,  it  is  not  likely  that  more  than  a  week 
will  pass  without  j'ielding  him  just  conclusions. 

Coming  now  to  the  investigation  of  cases  where  the  cause  is  to 
be  found  alone  in  some  cachexia,  we  have  only  to  refer  back  to  the 
general  features  of  disease  as  manifested  on  mucous  membranes. 

The  most  common,  and  indeed  not  very  unfrequeut,  cause  of  en- 
gorgement of  the  antrum — particularly  mucous  engorgement — is 
simple  catarrh  of  the  Schneiderian  membrane.  The  patient  takes 
a  cold,  the  excitement  expends  itself  about  the  nares ;  by  simple 
continuity  of  structure  the  lining  membrane  of  the  sinus  becomes 
vascularly  excited  ;  perhaps  the  duplication  at  the  orifice,  because 
of  greater  nearness  to  the  central  ring  of  inflammation,  becomes  con- 
gested to  such  extent  as  to  close  the  opening:  thus  we  have  the 
elements  for  engorgement,  and  the  mucus  thus  confined  will,  if  not 
vented,  sooner  or  later  act  as  such  a  source  of  irritation  that  it  will 
become  to  the  membrane  of  the  cavity  almost  precisely  what  the 
virus  of  gonorrhcea  becomes  to  the  same  character  of  membrane 
lining  the  urethra.  Trouble  from  this  cause  is,  however,  generally 
so  slight  and  so  quickly  over  that  it  is  seldom  prominently  marked, 
either  to  patient  or  practitioner. 

The  symptoms  designating  this  condition  are,  first,  simple  vascu- 
lar excitement  of  the  membrane  lining  the  nares,  accompanied  with 
increase  of  mucus. 

As  the  grade  of  inflammatory  action  advances  to  complete  con- 
gestion, the  excess  of  mucus  associated  with  the  immediately  pre- 
ceding stage  is  succeeded  by  a  most  uncomfortable  deficiency  in  the 
secretion. 

This  dryness  is  associated  with  all  nasal  inflammations  of  ad- 
vanced grade,  but  when  the  trouble  is  to  implicate  the  antrum  it  is 
even  specially  marked.  A  single  moment's  consideration  of  the 
parts  makes  this  very  plain  :  the  nares  are  the  natural  outlets  for 
the  antral  secretions  ;  in  ordinary  Schneiderian  catarrh  the  extensive 
secretory  surfaces  of  the  antra  are  comparatively  unafi"ected:  of 
course  they  serve  to  lubricate,  to  a  greater  or  less  extent,  the  pass- 
ages. When,  however,  the  grade  of  inflammation  is  of  sufficient 
extent  to  congest  the  duplicatures  of  membrane  which  form  the 
nasal  outlets,  then,  because  of  the  retention  of  the  mucus,  the  ex- 
treme dryness  is  induced.  This  excessive  dryness  may  be  said, 
therefore,  to  offer  the  first  diagnostic  sign  of  antral  engorgement 
from  simple  catarrh.     From  this  point  the  disease  advances  or  de- 


ANTRUM  OF  HIGHMOBE,  AND   ITS  DISEASES.     671 

clines.  If  it  declines,  the  trouble  may  have  proved  of  such  trifling 
inconvenience  as  scarcely  to  have  attracted  the  attention  of  prac- 
titioner or  patient.  If,  on  the  contrary,  it  advances,  the  patient 
will  soon  be  made  conscious  of  the  engorgement  by  a  sense  of 
growing  heaviness  in  the  cheek,  attended  by  pain  of  a  dull,  slug- 
gish character.  The  progress  of  the  disease,  from  this  condition, 
is  precisely  the  same  as  that  described  as  accruing  from  dental 
troul)les. 

Treatment. —  This  is  to  be  conducted  on  general  principles. 
Where  the  disease  is  seen  in  its  incipient  stage,  it  will,  perhaps,  be 
found  unnecessary  to  do  more  than  administer  a  saline  cathartic;  or, 
what  I  have  found  a  most  satisfactory  treatment  is  to  administer  to 
the  patient  at  bedtime  one-sixth  or  one-quarter  of  a  grain  of  sulphate 
of  morphia  dissolved  in  an  ounce  of  the  liquor  ammonias  acetatis. 
This  latter  treatment  will  seldom  be  found  to  fail  in  breaking  up 
these  limited  congestions. 

Where,  however,  the  disease  has  advanced  to  engorgement,  and 
the  antrum  is  found  to  be  enlarging,  it  may  be  necessary,  in  order 
to  insure  against  even  more  serious  lesions,  that  treatment  shall  be 
directed  immediately  to  the  cavity.  To  accomplish  this,  extract 
the  second  molar  tooth,  and  penetrate  the  cavity  through  the 
alveolus  of  the  palatine  fang ;  in  this  way  such  medication  as  may 
seem  indicated  may  be  readily  employed.  Indeed,  for  a  cure  it  may 
be  only  necessary  to  keep  the  wound  patulous,  leaving  the  rest  to 
nature,  or,  if  there  should  seem  a  lack  of  vital  force,  I  do  not 
think  a  much  happier  stimulant  can  be  employed  than  the  tincture 
of  iodine  before  recommended. 

Furuncular  Epidemics. — It  will  be  found,  I  think,  the  conclusion 
of  every  one  who  has  observed  in  the  direction,  that  during  the  ex- 
istence of  furuncular  epidemics,  mucous  and  purulent  engorgements 
of  the  antrum  are  more  than  usually  common.  This  is  not  strange, 
if  we  consider  the  epidemic  condition  in  the  light  of  an  exciting 
cause  alone  ;  for  in  no  single  instance  where  my  attention  has  been 
called  in  such  direction  have  I  been  unable  to  discover  a  predis- 
posing cause  in  a  dead  or  diseased  tooth.  The  same  condition  of 
things  exists  in  regions  where  the  intermittents  are  endemic.  All 
the  odontalgias  and  cephalalgias  of  such  a  country  are  apt  to  be 
quotidian,  tertian,  or  quartan.  Furuncle  is  a  condition  associated, 
it  would  seem,  with  some  derangement  of  the  digestive  or  cutaneous 
functions.  When  epidemic,  it  would  be  in  proof  that  a  condition 
existed  adverse  to  the  performance  of  certain  physiological  functions. 


672  OEAL  DISEASES  AND   SURGERY. 

With  the  existence  of  a  predisposing'  cause  of  disease  about  the 
antrum,  it  is  not  at  all  strange  that  the  addition  thereto  of  an  ex- 
citing cause  should  at  once  increase  the  effect  of  the  irritant  even  to 
the  production  of  active  disease  :  and  such,  in  truth,  is  the  case  : 
the  patient  escapes  the  purulency  of  boils,  but  he  has  puralency  of 
the  antrum. 

Treatment. — This  I  need  scarcely  refer  to:  it  consists,  first, 
in  removing  the  source  of  local  irritation  ;  secondly,  in  correcting 
the  constitutional  disturbances. 

Scorbutus. — This  diathesis,  as  may  be  inferred,  predisposes  to 
antral  purulency  and  ulceration.  To  understand  the  local  condition 
thus  induced,  it  would  be  only  necessary  to  examine  the  gums  in  an 
individual  so  afflicted :  the  condition  of  the  antrum  is  akin  to  the 
condition  of  the  mouth.  The  treatment,  to  be  successful,  must  be 
from  the  constitutional  stand-point.  If  injection  of  the  cavity  seems 
indicated,  it  must  be  gotten  at  as  before  directed,  or  a  canula  can  be 
passed  into  it  through  the  natural  opening  in  the  middle  meatus  : 
the  latter  is,  however,  difficult,  and  therefore  liable  to  objection. 

The  Exanthemata  are  said  to  associate,  not  unfrequently,  their 
sequela?  with  this  cavity.  Treatment  thus  demanded  could  need  no 
special  consideration :  it  would  be  a  treatment  founded  on  general 
principles. 

TJie  Mercurial  Diathesis. — I  have  before  referred  to  the  troubles 
of  the  cavity  thus  provoked.  Mercury  holds  a  ck)uble  pathological 
relation  to  the  antrum ;  it  predisposes  from  its  constitutional  rela- 
tions, and  actively  and  locally  excites,  through  the  periosteal  inflam- 
mation it  excites  in  the  alveoli  of  the  teeth.  (The  same  I  should 
also  have  remarked  of  scurvy.) 

Ti'eatment. — The  indications  here  ai"e  twofold.  Resolve,  if  pos- 
sible, the  inflammation  about  the  teeth  (see  chapter  on  Alveolar 
Abscess),  and  eliminate  the  mercury  from,  the  system.  The  chlorate 
of  potash  and  the  common  muriate  of  soda  are  valuable  medicines 
in  this  direction :  the  latter  I  frequently  employ,  and  with  marked 
success. 

Syphilis. — This  is  a  disease  which  it  might  be  inferred  would,  of 
course,  have  an  affinity  for  such  mucus-lined  surfaces  as  the  antrum. 
Now,  mine  may  be  a  singular  experience,  but,  in  contradiction  of 
many  authors  who  have  written  on  the  subject,  I  must  say  that, 
with  the  wide  scope  afforded  by  such  hospitals  as  that  of  the  Uni- 
versity of  Pennsylvania,  and  of  Elockley  (in  which  latter,  for  over 
a  year,  I  gave  the  study  of  the  venereal  disease  the  closest  attention), 


ANTRUM  OF  HIGHMOBE,  AND   ITS  DISEASES.     673 

I  was  unable  to  find  a  single  case  of  diseased  antrum  which  could 
with  justice  be  attributed  to  the  vice.  As  remarked  on  a  previous 
page,  cases  have  been  met  with  where  the  origin  has  been  traced  in 
such  a  direction  ;  and  I  will  not  deny  that,  in  some  cases,  this  origin 
may  be  justly  so  traced  ;  but,  in  every  example  that  I  have  seen, 
the  mercury  administered  for  the  cure  of  the  syphilis  has  seemed  to 
me  to  have  much  more  to  do  with  the  condition  than  any  dyscrasia 
induced  by  the  virus. 

Among  what  might  be  termed  the  anomalous  cases  of  antral  dis- 
ease, mention  may  be  made  with  benefit,  perhaps,  of  a  case  pre- 
sented at  my  clinic,  November  4,  1871,  being  a  patient  under  the 
charge  of  Dr.  Cruise. 

Patient,  infant,  two  weeks  old.  One  week  after  birth  the  atten- 
tion of  the  mother  was  first  called  to  an  uncommon  restlessness, 
which,  however,  was  quickly  found  associated  with  a  growing  swell- 
ing of  the  right  side  of  the  face,  the  eyelid  being  soon  closed  from 
oedema.  Examining  the  case  closely,  discovery  was  made  of  a  dis- 
tending antrum,  every  portion  of  the  common  wall  gradually  bulging. 
Pressure  upon,  the  roof  of  the  mouth,  with  counter-support  to  the 
cheek,  caused  a  slight  ejection  of  bloody  pus  from  the  nose.  A 
diagnosis  secured,  a  bistoury  was  passed  through  the  attenuated, 
softened  wall  of  the  canine  fossa,  the  withdrawal  of  the  blade  being 
attended  by  much  pus  and  blood. 

The  ti'eatment  of  the  case,  continued  by  Dr.  Cruise,  consisted  in 
the  frequent  injection  of  black  tea,  of  a  strength  as  prepared  for  the 
table.  Several  spiculse  of  bone  came  away,  leaving  the  little  patient, 
after  two  or  three  weeks,  in  what  might  be  termed  a  common  state 
of  health.  No  injury  was  known  to  have  happened  this  child  in  its 
passage  through  the  pelvic  straits.  The  mother  was  quite  hearty  ; 
the  father,  however,  was  scrofulous.  Three  still-births  had  preceded 
the  present  child. 

Cases  of  what  may  be  termed  mechanical  disease  of  the  antrum 
will  be  encountered  by  every  surgeon  in  the  persons  of  those  who, 
having  met  with  the  accident  of  limited  exposure  of  the  cavity,  are 
in  the  habit  of  wearing  plugs  of  cotton,  wax,  or  wood  in  the  break, 
which  plugs  escape  into  the  cavity.  The  treatment  required  is,  of 
course,  the  simple  one  of  petting  away  the  foreign  body, — a  matter, 
however,  not  always  easy  to  accomplish. 

43 


CHAPTER    XXXI  Y. 


THE    APHTHA. 


Aphthae  is  a  terra  which  every  reader  must  liave  remarlved  to  be 
associated  (like  the  word  epulis)  with  some  degree  of  confusion. 

In  the  Greek,  from  which  the  terra  is  derived,  there  are  two 
verbs  with  the  same  spelling, — aTzrw.  The  raeaning  of  the  one  is 
"  to  set  on  fire  ;"  that  of  the  other,  to  "  bind  to"  or  to  "fasten  upon." 

The  raouth  presents  ulcers  or  sores  of  various  signification, — 
some  wliich  are  characterized  by  pain  of  a  burning,  inflammatory 
character  ;  others,  chronic,  or  cold  in  nature,  furnish  an  inviting 
soil  to  a  very  persistent  and  almost  omnipresent  parasite,  —  the 
oidium,  —  this  fungus  fastening  upon  and  binding  such  sores  in  its 
necklace-like  embrace.  It  has  thus  very  naturally  occurred  that 
pathulogists,-  seeking  an  expressive  term  by  which  to  designate 
these  varying  conditions,  differently  employed  the  common  name  as 
it  happened  to  them  to  observe  or  adopt  the  one  or  the  other  of  the 
roots  from  which  the  expressions  were  derived.  That  such  uses  of 
the  dissimilar  verbs  on  the  part  of  various  authors  must  have  been 
made,  is  necessary  to  be  inferred  to  explain  the  differences  which 
characterize  their  descriptions. 

With  such  examples  of  liberty,  intentional  or  unintentional,  I  may 
be  excused  in  presenting  to  my  readers  the  subject  after  my  own 
manner  and  views. 

For  the  reasons  of  the  double  derivation,  and  for  others  which  I 
shall  proceed  to  present,  the  term  aphthae  cannot,  in  justice  and 
pathological  signification,  Ije  applied  to  a  particular  species  of  sore, 
but  must,  as  a  noun  of  multitude,  apply  to  a  class, — which  class  has 
many  species.  Thus  we  may  accept  as  explained  and  dismissed  the 
various  questions  of  ulceration  and  non-ulferation,  exudation  or  non- 
exudation,  the  oidium  or  no  fungi. 

The  type  of  the  aphihifi  is  as  follows:  An  aphtha  or  aphthous 
patch  is  a  degenerate  sore,  to  be  seen,  under  varying  circumstances, 
upon  the  mucous  surface  of  the  mouth,  the  fauces,  the  oesophagus,  and, 
(674) 


THE  APHTHA.  675 

quite  likely,  upon  any  part  of  the  alimentary  canal,  and  perhaps 
also  the  respiratory  tract.  The  most  common  seat  of  this  patch  is 
the  uvula ;  next  to  this  the  lower  lip  ;  next  the  tongue.  The  sore 
varies  in  size,  from  the  smallest  point  to  a  confluent  mass  which  may 
cover  a  large  surface ;  looks  pasty  or  exudative,  is  generally  oblong 
in  shape,  and  varies  in  color  from  the  misty  white  of  hoar-frost  to  the 
dirty  yellow  of  scrofulous  pus.  As  most  frequently  seen,  such  a  patch 
is  one  of  perhaps  several  similar  sores. 

This,  as  described,  is  the  typical  case.  From  it  we  are  prepared 
to  pass  to  the  general  view  of  the  subject. 

An  aphtha  is  a  canker;  nothing  more,  nothing  less.  Thrush,  fol- 
licular inflammation,  cancrum  oris,  gangraeua  oris,  are  all  species  of 
a  cancroid  class,  of  the  class  aphthae. 

What,  then,  is  aphthae?* 

The  modern  microscopist  exhibits  and  describes  aphthae  as  patches 
of  a  fu]Qgoid  excrescence, — the  oidium  albicans.  A  pot  of  paste,  a 
papered  wall,  a  section  of  apple  or  other  fruit,  the  leather  back  of  a 
book  or  chair,  exposed  to  a  confined  atmosphere,  hot  and  moist, 
quickly  produces,  or  rather  gives  attachment  to,  the  oidium. 

Oidium  albicans  is  not  a  disease,  is  not  aphthae;  neither  is  it  the 
expression  of  disease.  It  is  merely  a  fungous  growth,  accidentally 
associated  with  a  soil  and  circumstances  favorable  to  it  as  a  habitat. "f 

Aphthae  is,  without  doubt,  the  expression  of  a  cachexia,  and  is 
not  likely  to  be  a  merely  local  disease.     Neither,  I  conceive,  is  it 

*  The  term  is  here  employed  as  a  noun  of  multitude. 

f  Parasitic  fungi  (Hogg  on  the  Microscope) — vegetable  blights,  as  they  are 
commonly  called— have  of  late  years  become  objects  of  earnest  attention,  on 
account  of  the  enormous  damage  done  to  our  growing  crops,  and  also  of  the 
many  curious  facts  in  their  history  which  have  been  brought  to  light. 
Oidium  is  a  common  mildew. 

It  appears  that  at  particular  periods  of  the  year  the  atmosphere  is,  so  to 
speak,  more  fully  charged  with  the  various  spores  of  fungi  than  it  is  at  others. 
In  1854,  the  Eev.  Lord  Godolphin  Osborne,  during  the  cholera  visitation, 
exposed  prepared  slif  s  of  glass  over  cesspools,  gully-holes,  etc.  near  the  dwell- 
ings where  the  disease  appeared,  and  caught  what  he  termed  aerozoa, — 
chiefly  minute  spores  and  germs  of  fungi. 

From  this  same  year  (1854)  to  the  present  time,  we  have  amused  ourselves 
by  catching  these  floating  atoms,  and,  so  far  as  we  can  judge,  they  are  found 
everywhere,  and  in  and  on  everj'  conceivable  thing,  if  we  only  look  closely 
enough  for  them.  Even  the  open  mouth  is  an  excellent  trap.  Of  this  there 
is  ample  evidence,  since  we  find  on  the  delicate  membrane  lining  the  mouth 
of  the  sucking,  crying  infant,  and  on  the  diphtheritic  sore-throat  of  the  adult, 
the  destructive  plant  oidium  albicans. 


676  ORAL  DISEASES  AND  SURGERY. 

possible  for  the  fungus  to  be  peculiar  to  a  sore,  as  a  something- 
specific,  any  more  than  it  is  peculiar  to  the  paste,  the  fruit,  or  the 
book.  It  must  depend  in  the  one  instance,  as  in  the  other,  upon  an 
accidental  association.  This  accident,  in  the  case  of  the  sore,  would 
seem  to  be  the  absence  of  a  sufficient  vitality  to  enable  a  part  to 
resist  the  "  fastening  upon  itself  of  ever-present  parasites.  The 
microscopist,  if  I  may  be  allowed  to  suggest  it,  has,  in  his  examina- 
tions and  conclusions,  accepted  the  accident  and  overlooked  the 
disease. 

Thrush  or  muguet,  one  of  the  species,  is  an  erythematic  inflamma- 
tion, degenerating  after  a  few  days  into  a  condition  of  curdy  exuda- 
tion. The  inflamed  surface,  after  a  longer  or  shorter  time,  presents 
small  whitish  points ;  these  coalesce,  forming  the  exudate  patches. 
These  patches  vary  in  color:  as  they  remain  moist  and  clear,  they 
are  considered  with  least  apprehension  ;  as  they  grow  dry  and 
brown,  they  are  esteemed  possessed  of  dangerous  import. 

Dissections  of  the  cadaver  have  exhibited  aphthae  not  only  upon 
the  oesophageal  mucous  membrane,  but  also  on  other  parts  of  the 
alimentary  canal.  They  have  not  as  yet,  so  far  as  I  am  aware,  been 
met  with  upon  the  respiratory  tract ;  but  there  is  no  good  reason 
why  they  should  not  have  here  a  like  existence. 

In  an  acute  attack  of  thrush,  the  mouth  is  hot  and  the  general 
condition  feverish.  Milder  cases,  or  those  of  easy*  progress,  may, 
and  do,  seem — so  far  as  any  observable  constitutional  sympathy  is 
concerned — to  have  only  a  local  signification. 

But,  if  thrush  is  a  distinct  disease,  could  it  be  possessed  of  a 
double  signification  ?  Could  it  at  one  time  be  strictly  local,  at 
another  systemic?  Thrush  is  common  to  children  prematurely 
born  or  to  those  nursed  by  unhealthy  women.  It  is  a  disease  which 
belongs  to  hot,  moist  climates,  to  the  situations  of  uncleanly  hos- 
pitals ;  in  fact,  to  any  condition  recognized  to  be  depressive  of  the 
life-force;  it  is,  in  short,  a  systemic  adynamic  expression,  seated  on 
a  mucous  surface.  That  it  differs  from  carbuncle  or  cancrum  oris 
would  not  seem  to  be  the  case  in  fact,  but  only  in  degree.  Thrush 
is,  in  other  words,  one  expression  of  a  common  condition, — a  species, 
not  a  class. 

Follicular  inflammation — another  form  of  stomatitis  very  likely 
to  be  asthenic — is  a  term  used  to  signify  that  the  abnormal  vascu- 
lar change  is  seated  in  the  mucous  crypts  or  follicles.  In  passing 
the  finger  over  a  surface  so  inflamed,  the  studded  irregularity  pro- 
duced by  the  engorgement  of  the  glands  is  plainly  evident.     As 


THE  APHTHM.  677 

such  inflammatioa  progresses,  the  bodies  become  recognized  by  the 
eye  as  papular  eminences  standing  out  from  a  common  erythematic 
surface.  In  color  they  are  of  a  varying  red,  such  variations  in  shade 
expressing  the  constitutional  conditions. 

Follicular  inflammation  terminates  either  by  resolution  or  ulcera- 
tion :  when  in  the  latter  way,  the  follicles  soften  in  the  centre,  sup- 
purate, and  have  the  bottom  filled  with  a  whitish,  pasty  mass;  when 
in  this  condition,  they  are  the  aphthse  of  M.  Billard. 

Follicular  inflammation  appears  most  frequently  in  the  infant 
"during  the  deutitional  period, — an  explanation  existing  in  a  quickly 
and  easily  recognized  combination  of  a  predisposition  and  an  exci- 
tant. In  its  most  simple  form, — that  is,  where  there  is  no  marked 
dyscrasia,  or  where  the  excitant  is  not  of  sufficient  intensity  to  irri- 
tate to  any  extent, — the  lancing  of  the  gums,  or  the  application  of 
cooling  local  remedies,  may  be  sufficient  to  combat  or  control  the 
manifestations.  Where,  on  the  other  hand,  the  conditions  predis- 
posing to  the  disease  exist  in  a  state  of  balance,  as  it  were,  with  the 
natural  resistive  forces,  the  addition  of  a  second  depressant  influ- 
ence, as  that  resulting  from  the  irritation  of  dental  development, 
may  very  well  be  understood  as  giving  the  mastery  to  an  agent  or 
condition  otherwise  controlled  or  held  fully  in  check.  Thus  we 
explain  to  ourselves  the  real  and  ai)parent  connection  of  dental  irri- 
tation with  the  aphthae. 

From  a  simple  form,  or  the  inflammation  of  isolated  follicles,' the 
condition,  in  some  ill  states  of  the  general  system,  becomes  conflu- 
ent, such  extreme  form  being  most  frequently  noticed  in  the  typhoid 
exanthems,  or  in  destructive  organic  diseases.  In  confluent  follicu- 
lar inflammation,  a  prognosis  can  only  be  justly  made  when  every 
associate  and  collateral  influence  has  been  appreciated.  The  condi- 
tion will  nearly  always  be  found  an  occasion  for  anxiety. 

Cancrum  oris,  a  species  of  stomatitis,  generally  accorded  a  special 
classification,  differs  in  no  wise  from  that-just  considered,  except  in 
being  more  localized,  as  if  the  force  of  an  influence  had  concentrated 
rather  than  diffused  itself. 

The  complaint  known  as  cancrum  oris  is  an  asthenic  spreading 
ulcer.  In  appearance  this  ulcer  ditt'ers  from  what  has  been  given 
the  special  definition  of  aphthaj  by  most  writers,  only  in  being  more 
depraved  and  threatening.  It  has  the  same  pasty  bottom  of  vary- 
ing shades  of  white,  the  same  association  of  pain,  the  same  variation 
in  persistence.  Like  other  aphthae,  cancrum  oris  seems  to  l)e,  and  is, 
associated  with  dyscrasia,  appearing  most  commonly  in  the  infants 


678  ORAL  DISEASES  AND  SURGERY. 

of  ill-conditioned  charities,  in  the  ill  housed  and  poorly  fed, — having, 
in  all  systemic  associations,  the  precise  history  of  the  species  alluded 
to  as  thrush  and  glandular  inflammation. 

This  form  of  stomatitis,  although  confined  to  no  exact  locality,  is 
yet  most  commonly  met  with  on  the  cheeks  or  gums.  It  may  com- 
mence with  a  phagedenic  impression,  and  very  quickly  destroy  the 
patient ;  or  a  slight  vesicle  or  pustule  may  first  appear,  to  be  fol- 
lowed by  varying  inflammatory  associations,  precisely  as  if  some 
local  poison  was  the  source  of  the  trouble. 

The  history  of  cancrum  oris  differs  from  that  of  other  cancroid 
affections  only  in  degree.  This  is  fully  proven  in  the  facts  that  it  is 
associated  with  the  same  causes ;  that  any  ordinary  canker  sore  is 
capable  of  taking  on  an  ulcerative  action  ;  that  the  fungus  oidium  is 
quite  as  common  to  the  seat  of  this  as  the  other  affections.  In  fact, 
every  analogy  will  demonstrate  that  the  relation  is  like  that  which 
associates  the  phagedenic  with  the  simjjle  venereal  sore,  being  the 
difference  of  degree  and  not  of  cause  or  character. 

Gangrsena  oris,  sloughing  phagedsena,  is  another  expression  or 
species  of  the  common  class.  It  may  commence  as  an  acute  inflam- 
mation, quickly  deteriorating  ;  as  a  species  of  fatty  degeneration  of 
the  epithelial  tissue  ;  as  a  submucous  effusion  ;  or  as  an  eschar  which 
falls  from  its  relations  with  a  rapidity  that  leaves  us  at  a  loss  for 
an  explanation,  except  on  the  inference  that  the  materies  morbi  have 
had  the  most  special  concentration.  The  eschar,  formed  sooner  or 
later,  is  ashy  in  color,  or  a  deadish  brown,  while  the^  still  living 
parts,  particularly  the  external  cheek,  if  this  part  should  be  tlie  seat 
of  the  ulcer,  has  an  erysipelatous  blush, — white,  semi-livid,  and 
threatening  in  appearance. 

Gangrajna  oris  is  markedly  a  disease  of  the  dentitional  period, 
occurring  in  ill-fed,  ill-clothed,  or  ill-housed  children,  between  the 
first  and  second  dentitions.  Most  conspicuous  is  the  constitutional 
nature  of  this  affection.  It  is,  it  seems  to  me,  a  general  febrile  or 
inflammatory  disturbance,  concentrating  its  greatest  force  upon  some 
part  of  the  oral  cavity,  invited  or  directed,  withou.t  doubt,  by  the 
irritability  therein  existing, — proof  of  which  inference  lies  in  the 
fact  that  in  nearly  every  case  we  find  inflammatory  complications, 
such  associated  inflammations  being  most  frequently  found  in  the 
lung-tissue.  I  take  it  for  granted  that  the  oral  concentration  saves 
some  other  more  important  part. 

Gangraena  oris,  where  it  does  not  too  quickly  kill  and  separate 
hs  eschar,  affords  support  to  parasitic  fungi ;   the  oidium  albicans, 


THE  APHTHA.  679 

as  in  the  other  forms  of  aphthae,  being  that  most  frequeiitl}'  met 
with. 

Oral  gangrene  varies,  as  would  be  inferred,  in  degree  :  thus,  com- 
mencing as  a  single  canker  sore,  or  epithelial  degeneration,  and 
terminating  with  no  very  serious  result,  it  might  be  described  as  the 
follicular,  or  other  of  the  simple  species.  Concentrated,  or  in  its 
malignant  form,  it  destroys  life  without  affording  the  physician 
any  extended  chance  to  combat  it.  In  reasonably  healthy  children 
gangrene  is  very  uncommon,  the  ordinary  canker  being  generally 
the  worst  manifestation.  In  children  exhausted  under  the  exan- 
thenis,  in  those  maltreated  with  mercury,  or  those  laboring  under  a 
syphilitic  degeneration,  the  marked  or  destructive  type  is  exhibited. 

The  decomposition  of  mucus,  or  the  debris  remaining  from  the 
food,  when  lodged  upon  an  aphthous  sore,  forms  the  best  nidus  for 
the  development  of  fungi ;  it  is,  as  it  were,  a  soil ;  and  it  is  unde- 
niable that  epithelial  scales  in  varying  states  of  abnormal  degenera- 
tion, inspissated  mucus,  and  particles  of  decomposed  food  are  general 
to  all  such  sores.  Thus,  in  sickly  children,  the  fungoid  association 
is  most  common  from  the  fact  of  the  weakened  energy  of  the  parts 
afflicted;  this  favoring  decomposition  and  the  retention  of  the  debris 
in  the  cavity  of  the  mouth,  and  consequently  producing  the  required 
soil  or  habitat  of  the  oidium,  as  alluded  to. 

In  foundling-hospitals,  where  the  sucking-bottle  is  used,  the  spores 
of  fungus  find,  through  such  vehicle,  an  easy  passage  to  the  mouth, 
being  in  this  way  located  and  developed.  In  the  nursing  infant  of 
an  uncleanly  mother,  the  accumulation  and  retention  of  the  milk  will, 
with  favoring  atmospheric  Influences,  quickly  develop  fungi.  It  is 
the  fungus  and  not  aphtha  that  is  contagious,  as  must  be  plainly 
seen;  hence  one  can  but  wonder  at  the  disputes  of  Guersant, 
Billard,  Yalleix,  Duges,  and  others. 

Eeview. — Having  thus  expressed  my  own  views  of  aphthee,  com- 
mitting myself  to  the  admission  that  I  fail  to  distinguish  it  as  any 
special  disease,  I  may,  with  perhaps  greater  justice  to  the  subject, 
present  -the  opinions  of  others  whose  extended  observations  and 
judgment  have  long  held  them  in  the  light  and  position  of  authority. 
Trousseau  and  Delpech  both  describe  the  aphthae  as  being  sores 
with  the  materies  morbi  deposited  beneath  the  epithelium.  Bam- 
berger {Krankheiten  der  Mund  und  3Iiindhdhle)  controverts  tliese 
views,  and  explains  the  presence  of  the  soormasse  by  the  fact  that 
it  has  insinuated  itself  between,  among,  and  below  the  epithelial 
particles. 


680  ORAL  DISEASES  AND   SURGERY. 

"If  we  take,"  says  Professor  Bamberger,  "  the  soorniasse,  and  place 
it  under  the  microscope,  we  find  it  made  up  almost  exclusively  of 
epithelial  scales,  old  and  young,  the  debris  of  the  food,  and  of  in- 
spissated mucus,  which  last  is  probably  only  a  condition  of  epithe- 
lial formation.  The  color  of  the  mass  is  not  to  be  hastily  judged, 
as  this  might  have  been  influenced  by  the  debris  of  the  mouth. 

"Upon  these  sores,  however,  very  quickly  appears  a  peculiar 
organization,  which  consists  of  round  and  oval  spores  which  stick 
to  each  other,  and  in  this  way  form  a  more  or  less  ramifying  series 
of  threads.  The  longer  the  sore  continues,  the  more  marked  is  its 
penetration  by  these  threads  or  spores.  This  new  organization,  or 
fungus,  can  never,  however,  originate  or  be  generated  by  the  organ- 
ism itself,  but  is  always  the  result  of  germs  coming  from  outside 
sources.  It  is  not  peculiar  t6  a  particular  sore,  though  it  occurs 
most  frequently  on  those  of  a  certain  order.  Besides  the  two  con- 
stituent parts,  epithelial  scales  and  fungus,  there  appears  sometimes 
a  third  constituent,  in  the  form  of  granules  or  granulated  matter. 

"  From  this,"  continues  Professor  Bamberger,  "  we  see  that  aphthae 
cannot  be  counted  among  the  products  of  inflammational  and  exuda- 
tional  processes,  as  so  frequently  considered  ;  the  microscope  }ias 
failed  to  discover  an  exudational  appearance:  also  there  are  wanting 
the  anatomical  and  clinical  appearances  of  inflammation.  True,  it 
may  be  that  it  is  found  in  association  with  a  catarrh,  but  this  is  an 
accident,  just  as  one  may  not  sa}^  that  the  diarrhoea  so  frequently 
found  in  connection  with  the  sore  in  the  infant  is  the  cause  of  the 
sore,  as  he  might  not  say  that  the  sore  is  the  cause  of  the  diarrhoea. 
There  is,  in  aphtha,  no  ulceration,  the  soormasse  being  capable  of 
being  peeled  from  the  surface." 

Professor  Dewees  thus  refers  to  the  aphthae  as  exhibited  in  the 
infant : 

"This  complaint  is  generally  called  the  baby's  sore-mouth:  it 
consists  of  a  greater  or  less  number  of  white  vesicles  on  the  inside 
of  the  mouth.  It  very  generally  begins  on  the  inner  part  of  the 
lower  lip,  or  corners  of  the  mouth,  and  much  resembles' a  small 
coagulum  of  milk.  From  this  point  it  sometimes  spreads  itself  very 
rapidly  over  the  inside  of  the  cheeks,  tongue,  and  gums  ;  and,  at 
others,  it  will  appear  in  the  same  form,  and  at  the  same  time,  on 
several  portions  of  the  mouth;  as  inner  portions  of  the  cheeks,  etc. 
The  French,  especially  M.  Billard,  make  it  a  difi"erent  disease  from 
what  they  term  'muguet.'  But,  from  a  careful  examination  of  the 
two  diseases,  I  believe  them  to  be  the  same,  difl'ering  only  in  in- 


THE  APHTHM.  681 

tensity.  I  thiuk  we  have  not  the  disease  which  he  terms  '  muguet,' 
or  I  do  not  understand  his  description :  as  far  as  I  have  been  able 
to  compare  them,  they  are  identical.  The  difference  may  consist  in 
the  modification  which  a  hospital  may  give  it;  if  there  be  a  differ- 
ence, I  think  it  must  be  owing  to  this  cause.  When  this  efflores- 
cence is  extensive,  the  child  slavers  very  much,  and  is  frequently 
embarrassed  in  its  sucking;  it  cries,  and  evidently  betrays  that  it  is 
in  pain  ;  it  is  very  restless  and  very  thirsty,  as  it  evinces  by  its 
frequent  stirrings,  and  its  disposition  to  be  continued  at  the  breast. 
The  eruption  in  its  mildest  form  is  very  white,  and  looks  as  if  a 
stratum  of  milky  coagulum  were  spread  over  the  mouth.  It  some- 
times confines  itself  to  the  centre  of  the  cheeks,  at  others  to  the 
lower  lip,  or  one  side  of  the  tongue.  In  its  severer  forms  the  ap- 
pearance of  the  eruption  is  of  a  dark-brownish  color  or  extremely 
red,  owing,  most  probably,  to  minute  portions  of  blood ;  but  both 
are  evidently  grades  of  the  same  affection,  changed  either  by  mis- 
management, constitution,  or  the  force  of  the  remote  cause. 

"  This  affection  is  thought  to  be  altogether  of  a  symptomatic  kind, 
or  very  rarely  idiopathic.  It  is  almost  uniformly  preceded  by  a 
deranged  condition  of  the  stomach  and  alimentary  canal,  and  always, 
we  believe,  by  some  disturbances  of  the  stomach  itself.  The  brain 
always  shows  signs  of  participating  in  this  complaint,  as  there  is 
almost  always  an  unusual  inclination  to  sleep,  though  the  child  is 
frequently  disturbed  in  its  nap  by  some  internal  irritation,  perhaps 
of  the  bowels  themselves.  This  disposition  to  sleep  is  so  well  known 
to  nurses  that  they  will  frequently  tell  you  'the  child  is  sleeping  for 
a  sore-mouth.'  The  bowels  are  often  teased  by  watery,  acrid  stools, 
of  a  greenish  color  ;  their  discharge  is  frequently  attended  with  the 
eruption  of  much  wind,  and,  to  judge  from  the  noise,  it  would  be 
supposed  there  was  a  very  large  discharge  of  faeces,  though,  upon 
examination,  it  is  found  to  be  very  sparing. 

"The  alvine  discharges  are  frequently  very  acrid,  so  much  so, 
sometimes,  as  to  excoriate  the  verge  of  the  anus  and  nates  very 
severely,  especially  when  due  attention  is  not  paid  to  cleanliness 
or  to  the  frequent  changing  of  the  diapers.  But  this  never  takes 
place  until  the  disease  is  pretty  well  advanced,  and  has  made  some 
progress.  It  is  generally  pretty  well  spread  over  the  mouth,  and 
always  shows  a  violent  disease.  The  stomach  is  also  sometimes 
much  deranged ;  vomiting  the  milk  very  soon  after  it  is  received 
into  the  stomach,  in  the  form  of  a  dense  curd,  mixed  with  a  porra- 
ceous  mucous  substance.     If  the  milk  be  not  voided  by  vomiting, 


682  ORAL  DISEASES  AND  SURGERY. 

the  stomach  constantly  discharg-es,  Idv  eructations,  a  gas  with  a  very 
sour  smell.  The  child,  when  the  disease  is  sevei'e,  soon  becomes 
debilitated,  and  rapidly  emaciates;  it  is  almost  constantly  harassed 
by  severe  colics  and  profuse  diarrhoea;  its  stomach  will  scarcely 
retain  the  little  it  can  swallow;  the  oesophagus  sometimes  be- 
comes so  loaded  with  aphthae  that  it  can  no  longer  transmit  the 
small  quantity  which  is  reluctantly  admitted  into  the  mouth  ;  and 
the  child  dies,  either  from  the  exhaustion  consequent  upon  the  pro- 
fuseness  of  the  discharges  from  its  bowels,  or  from  inanition. 

"It  is  a  popular  belief  that  this  aphthous  efflorescence  passes  from 
the  mouth  through  the  whole  tract  of  the  alimentary  canal  to  the 
very  termination  of  the  rectum  ;  and  the  excoriation  at  this  part  is 
offered  as  evidence  of  the  fact.  Whether  this  be  true  or  not  we  do 
not  know,  for  we  are  not  in  possession  of  any  facts  from  dissection 
which  decide  the  point.  We  once  examined  a  body  which  certainly 
died  from  aphthae,  the  examination  of  which  would  by  no  means  tend 
to  confirm  this  common  belief.  A  child,  on  the  tenth  day  after  birth, 
was  observed  to  have  a  number  of  white  spots  upon  several  different 
portions  of  its  mouth,  which  rapidlv  spread  over  its  whole  surface. 
It  had  the  usual  premonitory  and  accompanying  symptoms,  which 
increased  daily  in  severity,  in  spite  of  every  effort  to  oppose  them. 
It  was  a  feeble,  weakly  child,  of  a  consumptive,  feeble  mother.  Its 
sufferings  were  very  great,  though  under  some  control  from  lauda- 
num, so  long  as  it  could  be  taken  b}^  the  mouth,  or  retained  by  in- 
jections. Coat  after  coat  of  aphthae  was  thrown  off,  and  each  new 
crop  appeared  to  be  more  abundant,  and  less  amenable  to  remedies, 
until  at  last,  at  the  end  of  two  weeks  of  severe  suffering,  the  poor 
infant  could  not  swallow  a  drop  of  the  thinnest  fluid.  Injections  of 
bark  and  mutton-tea,  in  conformity  with  popular  opinion,  were  re- 
sorted to,  but  all  in  vain  ;  the  child,  in  a  few  days  more,  died  from 
absolute  starvation,  or,  at  least,  the  catastrophe  was  certainh"  hurried 
by  the  impossibility  of  receiving  nourishment. 

"We  examined  the  body  after  death  :  we  found  the  whole  tract  of 
the  oesophagus  literally  blocked  up  with  an  aphthous  incrustation, 
to  the  cardia,  and  there  it  suddenly  stopped.  The  inner  coat  of  the 
stomach  bore  some  marks  of  inflammation,  as  did  several  portions 
of  the  intestines;  but  not  a  trace  of  aphthae  could  be  discovered 
below  the  place  just  mentioned.  This  case  would,  therefore,  create 
a  doubt  whether  this  affection  besieges  any  other  parts  of  the  body 
than  those  just  stated,  namely,  the  mouth,  posterior  fauces,  and  the 
oesophagus  to  the  cardia,  since,  perhaps,  none  could  have  been  of 


THE  APHTHAE.  683 

greater  severity;  but  it  is  with  us  a  solitary  case,  and  should  not  be 
received  for  too  much.  Dr.  Heberden  says,  '  The  aphthae  are  sup- 
posed not  only  to  infest  the  mouth  and  fauces,  but  to  be  continued 
down  through  the  whole  intestinal  canal.  In  two  who  died  of  lin- 
gering fever,  and  whose  mouths  were  covered  with  aphthae,  which 
hung  in  rags  all  over  it,  there  was  not  the  least  trace  of  them  that 
could  be  found  in  dissection  beyond  the  fauces.  '*  The  excoriations 
about  the  anus  can  certainly  be  accounted  for,  without  the  presence 
of  aphthae  to  produce  them  ;  in  bad  cases,  the  stools  are  always  ex- 
tremely acrid,  and  the  parts  over  which  they  constantly  pass  and 
spread  are,  at  such  a  tender  age,  very  delicate,  and  very  readily 
excited  to  inflammation. 

"  Dr.  Grood  seems  to  admit,  without  hesitation,  the  transmission  of 
aphthfe  through  the  intestinal  canal ;  for  he  says,  without  reserve, 
'  The  fauces  become  next  affected,  and  it  descends  thence  through 
the  oesophagus  into  the  stomach,  and  travels  in  a  continuous  line 
through  the  entire  course  of  the  intestines  to  the  rectum,  the  faeces 
being  often  loaded  with  aphthous  sloughs. 'f 

"  We  are  afraid  there  is  too  much  taken  for  granted  in  this  account  ; 
we  know  of  no  decided  evidence  of  the  fact,  nor  does  Dr.  Good  name 
any  authority  for  the  statement.  The  case  alluded  to  was  certainly 
one  of  death  from  aphthae  ;  but  in  it  the  aphthous  efflorescence  stopped 
at  the  cardia.  Is  it  probable  that  any  child  could  survive  this  affec- 
tion did  it  travel  the  whole  course  of  the  intestinal  canal?  "We 
think  not:  yet  aphthae  is  rarely  a  dangerous  disease  in  infancy.  Dr. 
Good's  description  of  this  affection  would  certainly  lead  to  the  con- 
clusion that  it  is  the  ordinary  march  of  the  disease  to  pass  through 
the  bowels  and  manifest  itself  at  the  verge  of  the  anus.  This  point 
is  far  from  being  settled  in  the  minds  of  pathologists:  even  the 
French  are  far  from  having  ascertained  it  with  certainty ;  it  is  true 
M.  Billard  says  he  has  seen  evidences  of  it  in  the  large  and  small 
intestines,  as  well  as  the  stomach  ;  but  there  is  no  mention  of  it 
lower  than  the  ileum. 

"  Now,  this  cannot  be  so  ;  since  It  is  in  violent  and  long-protracted 
cases  alone  that  the  anus  discovers  any  signs  of  irritation  from  this 
cause,  which  would  not  be  the  case  were  Dr.  Good's  account  correct. 

*  Commentaries,  p.  31.  "  It  is  well  known,  too,  that  in  smnlljwx  no  pus- 
tules are  traced  beyond  the  pharynx  and  larynx,  even  in  the  most  severe 
cases,  when  the  mouth  and  tongue  are  thickly  covered  with  the  eruption." — 
Tweedie's  Illustrations,  p.  65. 

•f  Study  of  Medicine,  vol.  ii.  p.  391. 


684  ORAL  DISEASES  AND  SURGERY. 

"  Dr.  Good  and  others  suppose  that  aphthae  communicates  itself  by 
a  specific  contagion,*  and  give  as  evidence  the  excoriations  of  the 
nai'se's  nipples.  We  do  not  hesitate  to  believe  there  is  a  discharge 
from  these  little  pustules  which  may  be  highly  acrimonious  to  the 
denuded  skin  ;  but  we  think  this  is  perfectly  innoxious  to  a  sound 
one.  For  we  have  never  seen  sore  nipples  produced  by  aphthse, 
where  the  skin  of  these  organs  was  perfectly  sound.  That  they 
aggravate  the  tenderness  and  inflammation,  when  these  parts  are 
tender  and  abraded,  we  admit,  and  so  would  any  other  acrid  sub- 
stance, without  having  recourse  to  the  belief  of  a  specific  contagion. 
If  this  were  the  case,  why  do  not  the  lips  of  children  laboring  under 
this  affection  betray  its  influence  ? 

"That  this  complaint  is  occasionally  epidemic  there  is  every 
reason  to  believe;  and  this  circumstance,  among  some  others  to  be 
mentioned,  renders  the  opinion  so  commonly  credited  (of  its  being  a 
sympathetic  affection)  very  questionable.  We  have  always  con- 
sidered aphthse  as  arising  from  some  peculiar  condition  of  the  stomach  ; 
but,  from  some  late  cases  and  more  mature  reflection,  we  think  it 
may  be  otherwise.     Our  reasons  for  doubt  are, — 

"  1.  We  have  recently  seen  this  affection  in  two  cases  where  the 
stomach  and  bowels  were  in  the  most  perfect  order  before  the  erup- 
tion, but  became  disturbed  a  little  during  the  progress  of  the  disease. 

"  2.  That  this  complaint  has  been  very  often  removed  by  topical 
applications  alone,  where  the  efflorescence  has  been  very  consider- 
able, and  where  there  was  no  remedy  of  an}^  kind  addressed  to  the 
stomach  and  bowels. f 

"  3.  That  we  do  not  uniformly  see  this  complaint  where  there  has 
existed  great  disorder  of  both  stomach  and  bowels,  and  these  of  a 
permanent  kind. 

"4.  That,  however  the  stomach  and  bowels  may  be  disturbed  by 
acidity  or  other  inconvenience,  or  however  long  these  may  continue, 
if  the  child  has  had  this  complaint,  it  is  not  renewed,  though  the 
individual  is  not  exempt  from  a  second  attack,  like  measles  or  small- 
pox ;  for,  in  certain  chronic  affections,  they  may  be  again  visited  by 
aphthse. 

"  5.  That  this  affection  is  sometimes  epidemic,  as  stated  above  ; 
for  Dr.  Good  informs  us  that  not  only  all  the  children  of  the  same 

*  M.  Billard  declares  it  not  to  be  contagious. 

t  Query. — Is,  then,  the  unconquerable  diarrhoea,  sometimes  present,  a 
mere  accident,  or  would  it  not  be  more  easy  to  account  for  it  by  the  presence 
of  aphthae? 


I 


THE  APHTHuE.  685 

family,  however  cautiously  separated  from  one  another,  but  many  of 
those  of  the  same  neighborhood,  have  been  known,  at  times,  to 
suffer  from  it  simultaneously.     (Vol.  ii.  p.  391.) 

"6.  That  this  disease  is  almost  always  ushered  in  by  some  cere- 
bral atfection,  as  great  drowsiness  or  watchfulness ;  the  first  is  by 
far  the  most  common. 

"  7.  That  other  portions  of  mucous  membranes  are  liable  to  the 
same  kind  of  eruption,  without  the  condition  of  stomach  or  bowels 
being  instrumental  in  its  production;  for  we  have  seen  it  most 
plentiful  within  the  labia  pudendi,  as  well  as  on  the  internal  face  of 
the  prepuce. 

"  These  facts  have  made  us  lately  question  the  sympathetic  origin 
of  aphthae:  yet  we  admit  they  are  not  altogether  conclusive  in  our 
own  mind  ;  but  we  thought  it  proper  to  suggest  the  possibility  of  its 
being  an  idiopathic  disease  of  the  mucous  membrane. 

"  This  affection  is  not  confined  to  early  infancy;  it  shows  itself  in 
the  more  advanced  periods  of  childhood,  and  from  that  to  any  period 
of  human  life.  It  is  sure  to  attend  the  last  stages  of  almost  every 
long-protracted  disease,  especially  those  which  may  have  wasting 
discharges,  such  as  phthisis  piilmoualis,  dysentery,  or  diarrhoea; 
and  when  it  does  appear,  it  is  almost  sure  to  be  a  fatal  harbinger. 

"This  disease  is  not  essentially  accompanied  with  fever;  if  it 
accompany  any  chance  affection  which  is  attended  by  fever,  we  do 
not  find  it  to  heighten  the  existing  one. 

"Weakly  children,  and  especially  those  born  before  their  full 
period,  are  more  obnoxious  to  this  complaint  than  the  robust  and 
those  who  have  tarried  to  their  full  time  in  the  uterus:  the  children 
of  weakly  women,  and  particularly  those  who  make  bad  nurses 
from  scarcity  of  milk,  or  from  its  not  being  of  a  sufficiently  nutritious 
quality,  are  more  disposed  to  this  affection  than  the  children  of  hale 
w^omen,  who  have  plenty  of  nourishment  of  good  quality.  The 
children  fed  much  upon  farinaceous  substances  are  especiallv  ex- 
posed to  the  attack  of  this  disease,  particularly  when  their  food  is 
sweetened  with  brown  sugar  or  molasses." 

In  the  work  by  M.  Jourdain  "  On  the  Surgical  Diseases  of  the 
Mouth"  is  a  chapter  on  aphthae,  so  unlike  all  that  precedes  it,  as 
connected  with  modern  pathology,  that  I  cannot  but  think  the  book 
owes  the  presence  of  the  chapter  to  the  translator  rather  than  to  the 
author. 

"The  term  aphthae,"  says  this  work,  "is  used  alike  by  ancients 
and  moderns,  but  in  quite  a  different  acceptation.  The  former  define 


686  ORAL  DISEASES  AND  SURGERY. 

aphthae  as  superficial  malignant  ulcers,  attended  with  heat,  occurring 
especially  in  infants,  and  not  confined  to  the  mucous  membrane  of 
the  mouth.  It  is  at  the  present  day  universally  applied  to  those 
whitish  pustules  which  appear  on  the  mucous  membrane  of  the 
mouth,  and  sometimes  of  the  adjoining  parts.  Inattention  to  this 
difference  has  led  many  to  apply  to  the  latter  disease  a  treatment 
based  upon  the  definition  of  the  ancients,  whereas  the  two  are  pal- 
pably different. 

"Aphthae  have  been  regarded  as  ulcers;  but  ulceration  implies 
solution  of  continuity,  whereas  in  true  aphthae,  there  is  no  erosion 
or  decrease  of  substance,  but,  on  the  contrary,  an  increase  ;  desqua- 
mation of  the  aphthous  crust  leaves  no  trace  of  cicatrization.  Theo- 
rists speak  of  white,  red,  nnd  l)laclv  aphthae,  according  to  the  nature 
of  the  generating  humor;  but  during  a  long  practice  I  have  never 
seen  them  of  any  other  color  than  white,  whitish,  or,  especially  when 
of  an  unfavorable  character,  ash-colored. 

"They  commence  by  small  white  spots,  usually  on  the  uvula, 
thence  spreading,  sometimes  over  the  veil  of  the  palate,  sometimes 
over  the  tongue,  gums,  and  inside  of  the  lips  and  cheek.  Often 
they  spread  still  farther  into  the  pharynx  and  oesophagus.  Of  their 
extension  beyond  this  we  cannot,  of  course,  have  the  evidence  of 
sight;  but  we  have  other  and  unequivocal  symptoms,  which  prevent 
us  from  regarding  as  an  absurdity  the  idea  of  their  presence  in  the 
oesophagus,  stomach,  and  smaller  intestines;  as,  for  instance,  in  the 
difficulty  of  breathing  and  deglutition  ;  also  in  the  appearance  of  the 
discharges  from  the  stomach  and  bowels,  so  frequent  in  aphthous 
disease. 

"  The  description  of  aphthae  is  easier  than  their  etiology.  We 
maintain  that  they  depend  in  all  cases  upon  the  same  cause,  differing, 
indeed,  in  degree  of  intensity,  but  never  in  its  nature.  We  therefore 
differ  from  those  who  assign  one  cause  in  adults  and  another  in  in- 
fants. Nor  can  we  agree  with  the  many  who  make  them  to  arise 
from  excess  of  serum  or  of  acid  in  the  milk  or  nourishment  given  to 
the  infant.  The  depleting,  purging,  and  starving  treatment  based 
upon  this  hypothesis  is  most  pernicious  ;  moreover,  experience  tells 
us  that  this  very  acidity  or  astringency  of  aliment  will  frequently 
cure  aphthous  eruptions,  or  prevent  them  from  coming  to  maturity  ; 
and  a  serous  flux,  determining  to  the  mouth,  has  caused  the  complete 
disappearance  of  existing  aphthte. 

"What,  then,  is  the  true  origin  of  this  disease?  We  believe  it 
to  be  found  in  the  existence  of  a  slow  and  imperfect  crisis,  and  to 


THE  APHTHA.  687 

arise  from  a  sulphurous  humor  generated  in  the  larger  vessels,  and 
determining  to  such  parts  as  are,  by  position  or  structure,  most  im- 
pressible. Observe  for  a  moment  the  circumstances  and  character 
of  aphthae.  In  all  fevers,  in  the  young  and  in  the  vigorous,  their 
appearance  is  ever  preceded  by  a  crisis  more  or  less  distinct,  and, 
according  to  the  violence  of  the  primary  disease,  marked  by  more  or 
less  severe  symptoms.  In  one  case  nature  struggles  successfully 
with  the  acrimonious  morbific  principle,  a  favorable  crisis  occurs, 
and  an  aphthous  eruption  brings  great  relief  to  the  patient;  in 
another  case  this  morbific  principle  is  too  abundant,  obstinate,  or 
malignant. — no  crisis  occurs, — no  aphthae, — nature  succumbs,  and 
the  patient  dies.  Again,  we  have  aphthae  through  the  critical  transfer 
of  morbid  action  from  some  more  or  less  vital  and  important  organ. 
In  some  cases  the  change  proves  salutary  ;  in  others  there  is  a  reac- 
tion, the  aphthjB  disappear,  and  if  the  vih  vitse  be  not  destroyed,  it 
is  often  greatly  endangered. 

"  Aphthae  rarely  occur  in  a  perfect  and  favorable  crisis,  but  rather, 
as  we  have  before  said,  in  those  which  are  slow  and  imperfect,  such 
as  are  met  with  in  a  great  number  of  diseases.  Thus  we  find  some 
aphthous  eruptions  of  not  only  days',  but  weeks'  and  mouths'  con- 
tinuance. When,  for  instance,  necessary  evacuations  have  been 
neglected  in  the  onset  of  disease,  and  a  cachectic  plethora  has  super- 
vened, the  cure  is  slow  and  incomplete  without  the  occurrence  of 
aphthae.  Diuretics  and  gentle  enemas  aid  the  recovery  ;  blood-let- 
ting and  purgatives  retard  it:  the  aphthae  disappear  after  fulfilling 
their  sanative  purpose,  and  the  patient  feels  perfectly  relieved.  Ex- 
perience, however,  shows  that  the  danger  is  not  quite  over-:  some 
lurking  matter  may  take  fresh  increase,  give  rise  to  new  aphthae, 
in  default  of  other  means  of  escape  from  the  system,  and  greatly 
endanger  life ;  this  may  happen  twice,  or  thrice,  or  oftener. 

"  The  causes  or  antecedent  symptoms  of  aphthte  may  be  mild,  and 
recovery  take  place  with(»ut  any  or  with  very  simple  treatment;  or 
they  may  be  severe  and  lamentable,  ending  in  suffocation,  delirium, 
or  obstinate  diarrhoea.  This  difference  we  find  explained  by  the 
varying  state  of  the  humors  :  at  one  time  being  crude,  and  b}^  con- 
sequence irritating,  at  another  time  matured  or  concocted,  by  which 
process  of  concoction  the  more  hurtful  principles  are  expelled, — a 
process  aided  in  some  inexplicable  manner  by  the  continued  circu- 
lation of  the  animal  spirits.  Thus  it  happens  that  the  aphthae  of 
seventh-day  crises  are  usually  more  unfavorable  than  those  which 
follow  crises  of  a  later  date,  when  the  morbid  matter  has  had  time 
to  undera-o  a  thorough  concoction. 


688  OBAL  DISEASES  AND  SURGERY. 

"Although  aphthffi  are  most  generally  preceded  by  febrile  mias- 
mata, they  are  not  necessarily  so.  I  have  seen  cases,  both  among 
adults  and  infants,  in  which  they  have  been  neither  preceded  nor 
attended  by  fever.  In  infants  we  may  properly  suspect  impurity 
of  the  mother's  blood. 

"Certain  evacuants  have  been  found  more  hurtful  than  beneficial 
in  the  treatment  of  aphthse.  This  comes  from  a  forgetfulness  of  the 
excellent  advice  of  Hippocrates,  who  tells  us  to  have  regard,  in  the 
choice  of  depleting  agents,  to  the  channels  of  evacuation  which 
nature  points  out  in  any  given  case.  Now,  the  vessels  concerned  in 
the  critical  discharge  of  an  aphthous  eruption  are  the  lymphatic 
rather  than  the  venous  or  arterial  vessels.  Therefore  to  the  changes 
of  the  lymphatic  fluid,  rather  than  to  those  of  the  blood,  is  our  atten- 
tion to  be  mainly  directed  in  the  management  of  this  disease.  We 
have  frequent  evidence  of  serous  or  lymphatic  engorgement  at  the 
outset  of  aphthous  eruptions  :  in  the  fever,  stupor,  and  restlessness 
during  sleep, — indicating  a  fullness  of  the  head  and  an  acrimony  of 
the  humors. 

"Aphthae  are  more  common  in  some  countries  than  in  others, 
whicli  explains  the  almost  total  silence  of  some  writers  respecting 
them.  This  depends  upon  diiference  in  climate  and  mode  of  living. 
In  warm  countries  their  course  is  rapid,  from  the  increased  perspira- 
tory action  of  the  skin.  But  in  colder  latitudes,  where  the  food  is 
coarser,  the  habit  of  body  denser,  and  the  humors  thicker,  their 
progress  is  slower,  because  the  secretions  of  the  system  generally 
are  more  liable  to  obstruction.  In  these  countries,  especially,  all 
discharges  which  tend  to  arrest  perspiration,  such  as  hemorrhoidal, 
intestinal,  or  uterine,  whether  occurring  spontaneously  or  artificially 
provoked,  are  very  unfavorable  in  the  treatment  of  aphtha?.  On  the 
contrary,  a  copious  cutaneous  or  urinary  secretion  forms  often  a  favor- 
able crisis.  This  agrees  with  the  doctrine  that  aphthae  are  essentially 
serous,  and  most  readily  cured  by  a  free  discharge  of  serum  or  lymph. 
The  cause  of  endemics  we  leave  others  to  explain ;  each  country 
bears  in  its  womb  the  seeds  of  its  own  diseases,  and  also  the  means 
for  their  cure.  External  agencies  may  cause  aphthae,  not,  as  the  an- 
cients supposed,  by  their  direct  action  on  the  mouth,  but  indirectly, 
through  the  mass  of  the  circulating  fluids. 

"  The  diagnosis  of  aphtha  is  easy  ;  not  so  the  correct  interpreta- 
tion of  their  premonitory  symptoms.  Painful  deglutition,  dryness 
of  the  mouth,  a  thick,  husky  voice,  heat  of  the  ston)ach,  with  rum- 
bling noises,  disturbed,  unfreshing  sleep, — these  often  precede  aph- 


THE  APHTHA.  689 

thous  eruptions.  Urinary  symptoms  are  not  to  be  relied  upon,  though 
often  useful  in  prognosis  after  the  appearance  of  the  eruption.  In 
tbe  different  forms  of  fever,  the  obstinacy  of  the  disease  is  often  a 
precursory  symptom  ;  when,  notwithstanding  the  intestinal,  urinary, 
and  other  evacuations,  there  still  exist  great  depression  and  em- 
barrassment of  the  vital  functions,  the  appearance  of  aphthae  will 
often  in  a  single  night  bring  calm  and  relief  to  the  patient,  as  ex- 
perience has  abundantly  testified.  The  physician  should  follow 
nature's  hint,  and  seek  to  aid  in  the  cure  of  the  disease  through  the 
same  channels.  The  above  symptoms,  be  it  understood,  are  by  no 
means  necessarily  followed  by  aphthous  eruptions. 

"We  should  be  careful  in  our  prognosis:  where  the  system  is  not 
weakened,  the  pre-existing  morbid  matter  well  concocted,  or  the 
extent  of  the  eruption  limited  to  the  palate,  we  may  anticipate  a 
favorable  issue.  But  if  the  patient  be  in  a  reduced  and  weakened 
condition,  the  morbid  matter  crude,  or  the  aphthae  covering  the  entire 
membrane  of  the  mouth  and  pharynx,  the  disease  is  much  more  to 
be  feared.  Again,  suppression  or  derangement  of  the  menstrual  flux 
is  unfavorable,  from  its  tendency  to  draw  the  eruption  from  the 
place  where  alone  it  can  properly  mature.  Profuse  alvine  or  hemor- 
rhoidal discharges  are  also  hurtful ;  also  any  catarrhal  attack  falling 
upon  the  throat,  causing  tbe  sudden  disappearance  of  the  aphthae. 
Aphthas  occurring  in  diseases  at  the  onset  of  which  there  was  in- 
suflScient  evacuation,  are  grave  and  dangerous.  The  disease  may 
occur  in  persons  of  either  sex,  and  be  of  tedious  duration;  but  when 
the  appetite  returns,  not  only  is  the  food  highly  relished,  but  it  gives, 
by  its  new  nourishment,  relief  and  salutary  benefit." 

"The  term  aphthae,"  says  Prof.  Wood,  in  his  "Practice  of  Medi- 
cine," vol.  i.  page  501,  "  was  employed  by  the  ancients  to  signify 
various  inflammatory  affections  of  the  mucous  membrane  of  the 
mouth.  Willan  proposed  to  restrict  it  to  a  peculiar  vesicular  eruption 
upon  the  membrane,  but  committed  the  error  of  confounding  with  this 
aflfection  the  thrush  of  early  infancy.  The  two  complaints  are  quite 
distinct,  and  should  not  be  similarly  designated.  Aphthge,  in  com- 
pliance with  very  general  custom,  is  extended  to  all  those  small 
ulcers,  with  whitish  surface,  which  so  frequently  appear  in  the 
mouth,  whatever  may  be  their  origin.  The  most  frequent  source 
of  aphthae  is  probably  the  vesicular  eruption  occasionally  present  in 
erythema.  The  vesicle  is  small,  oval,  or  roundish,  white  or  pearl- 
colored,  and  consists  of  a  transparent  serous  fluid  under  the  elevated 
epithelium.    In  a  few  days  the  epithelium  breaks,  the  serum  escapes, 

44 


690  ORAL  DISEASES  AND   SURGERY. 

and  a  small  ulcer  forms,  more  or  less  painful,  with  a  whitish  bottom, 
and  usually  a  red  circle  of  inflammation  around  it.  The  vesicles  are 
sometimes  distinct  and  scattered,  sometimes  numerous  and  confluent. 
The  distinct  variety,  though  painful,  is  a  light  affection,  continuing 
in  general  only  a  few  days  or  a  week,  and  is  usually  confined  to  the 
mouth.  It  produces  little  or  no  constitutional  disorder,  though  it 
may  be  associated  with  fever  and  gastric  irritation  as  an  effect.  It 
attacks  equally  children  and  adults,  but  is  said  to  be  very  common 
in  early  infancy.  In  adults  it  is  frequently  occasioned  by  the  irrita- 
tion of  decayed  teeth.  The  confluent  variety  is  much  more  severe 
and  obstinate.  This  frequently  extends  into  the  fauces  and  pharynx, 
and  is  said  to  reach  even  the  intestinal  canal,  though  it  may  be 
doubted  whether  the  affection  of  the  stomach  and  bowels  is  identical 
with  that  of  the  mouth." 

The  French  fail  in  distinguishing,  with  Prof.  Wood,  the  difference 
between  the  pultaceous  inflammation  of  thrush,  or  muguet,  and  the 
aphthae,  calling  muguet  the  "  aphthes  des  enfans."  They  recognize 
also  that  there  are  variations  in  the  expressions  of  the  condition, 
making  a  distinction  between  the  muguet  benin  ou  discret,  and  the 
confluent,  muguet  malm  ou  conjiuent. 

In  Clymer's  Aitken's  "  Science  and  Practice  of  Medicine,"  the 
subject  is  thus  alluded  to:  "Follicular  inflammation  of  the  mouth, 
follicular  stomatitis,  aphthous  stomatitis,  or  aphthae  of  the  mouth,  is 
a  disease  which  usually  commences  as  a  simple  stomatitis  ;  but 
very  soon  small,  round,  transparent,  grayish  or  white  vesicles  appear, 
and  at  the  base  of  each  is  an  elevated  marginal  ring,  which  is  pale 
and  firm.  Fluid  soon  escapes  from  the  ruptured  vesicle ;  an  ulcer 
forms,  which  spreads,  bounded  by  a  red  circle  and  an  elevated 
border.  In  some  forms  of  the  affection  microscopical  parasitic 
plants  appear." 

Treatment. — If  we  are  content  to  view  aphthae  simply  as  a  fun- 
gous sore,  oi'iginating  from  and  maintained  by  the  presence  of  a 
parasite, — the  oidium  albicans, — we  would  find  a  most  admirable 
application  in  carbolic  acid,  admitting  that  the  parasite  had  an  ex- 
ternal relation  only;  if,  however,  these  spores  come  from  within 
and  are  exudational,  such  local  treatment  would  be  of  very  temporary 
service. 

Yiewing  the  fungus  simply  as  an  accidental  parasite  external  in 
its  relations,  our  attention  is  directed  primarily  to  the  necessity  for 
cleanliness,  and  the  avoidance  of  all  positions,  locations,  and  circum- 
stances favoring  the  development  of  fungi:  carbolic  acid,  acid  nitrate 


THE  APHTHA.  691 

of  mercury,  sulphuric  acid,  nitrate  of  silver,  or  chloride  of  zinc,  will 
be  found  destructive  to  the  parasite,  and,  of  necessity,  if  the  circum- 
stances are  changed,  equal  to  the  production  of  a  permanent  change 
in  the  appearance  of  the  part ;  that  is  to  say,  the  application  is  equal 
to  the  removal  of  the  envelope  or  cover  of  the  disease,  but,  except  by 
a  happy  accident,  will  not  beneficially  affect  the  underlying  condition, 
or  the  disease  proper. 

In  the  treatment  of  aphthae,  the  practitioner  finds  himself  com- 
pelled, at  the  very  outstart,  to  consider  the  constitutional  associa- 
tions. Occurring  in  connection  with  acute  diseases,  it  is  generally 
the  case  that  the  local  expression  is  found  to  disappear  with  the 
condition  exciting  it.  Thus,  in  febrile  attacks  attended  with  stoma- 
titis, we  direct  our  remedies  to  the  causes  inducing  such  attacks ; 
as  the  functions  become  harmonized  and  regulated,  the  expressions 
of  the  irregularity  disappear. 

Aphthae,  whatever  its  form,  appearing  in  connection  with  the 
dyscrasic  diseases,  gives  to  the  practitioner  the  greatest  anxiety  and 
trouble.  In  our  anticipations  of  what  we  are  to  do,  we  are  not  to 
forget  that  the  task  before  us  is  the  removal,  or,  at  least,  the  marked 
amelioration,  of  the  constitutional  disease.  If  this  should  be  syphi- 
litic, tubercular,  or  cancerous,  the  magnitude  of  the  task  is  evident : 
hence  it  is  that  patients  are  allowed  so  frequently  and-so  unneces- 
sarily to  find  themselves  subjected  to  a  series  of  disappointments. 

Acute  aphthae,  as  manifested  in  cancrum  oris,  gangraena  oris,  and 
follicular  inflammation,  demands  not  unfrequently  the  most  attentive 
local  treatment.  This  treatment  has,  however,  nothing  particularly 
special  in  it,  and,  without  doubt,  must  be  appreciated  from  the 
general  expressions  of  the  subject.  Alteratives  and  soothing  appli- 
cations are  such  as  would  naturally  commend  themselves.  Sulphate 
of  copper,  in  proportions  varying  from  five  to  thirty  grains  to  the 
ounce  of  water,  is  an  excellent  application.  Iron  and  quinine  in 
combination  are  used  to  great  advantage, — twenty-five  grains  of  the 
latter  to  one  drachm  of  the  muriated  tincture.  A  powder  made  by 
combining  equal  parts  of  red  bark,  chalk,  and  tannic  acid  is  fre- 
quently found  very  serviceable.  Solutions  of  alum,  and  the  tinc- 
tures of  capsicum  and  myrrh,  are  useful  in  their  places  ;  also  borax, 
.oxalate  of  cerium,  powdered  chlorate  of  potash,  sulphate  of  iron,  etc. 
Hydrochloric  acid,  applied  by  means  of  a  feather  or  small  brush, 
causes  less  pain  than  might  be  supposed,  and  is  thought  by  many 
to  be  the  very  best  local  application  that  may  be  employed. 

Where  the  parts  seem  angry  and  irritable,  or  phagedenic,  com- 


692  ORAL  DISEASES  AND  SURGERY. 

bined  with  these  applications  are  to  be  employed  the  more  soothing 
means:  starch,  gum,  and  slippery-elm  water  being  found  in  such 
directions  very  serviceable.  Tincture  of  hamamelis,  much  diluted, 
is  a  good  preparation.  Another  is  the  phenate  of  soda.  It  is  to  be 
understood  that  while  the  principles  which  govern  the  treatment  of 
the  aphthae  are  common  to  the  species,  the  applications  must  vary 
to  meet  varying  local  indications.  The  ordinary  white  sores,  for 
example,  need  little  more  in  the  way  of  such  direct  treatment  than 
the  continued  application  to  them  of  some  of  the  agents  mentioned: 
which  one  would  be  best,  or,  indeed,  what  would  be  best,  we  could 
not  well  say,  unless  considering  a  particular  case.  The  local  treat- 
ment is  not,  however,  in  any  of  these  cases  urgent,  and  it  is  the 
general  experience  that  we  find  ourselves  trying  first  one  thing  and 
then  another;  indeed,  it  is  unfortunately  too  common  that  we  are 
soon  brought  to  the  conviction  that  any  local  application  is  un- 
reliable,— not  that  we  cannot  cause  a  sore  to  disappear,  but  that 
to-day,  to-morrow,  or  next  week,  another  comes  to  take  its  place. 
Canker  sores  seem  periodic  in  some  persons ;  they  come  without 
perceptible  cause  other  than  what  seems  a  persistent  constitu- 
tional condition,  defy  all  treatment,  and  finally  disappear  of  their 
own  accord. 

Of  the  special  conditions,  thrush  demands  that  the  bowels  should 
be  kept  free  from  costiveness, — oil,  the  saline  cathartics,  or  aloes 
being  employed  as  indicated.  Where  fever  attends  the  local  mani- 
festation, it  is  well  to  prescribe  the  neutral  mixture  made  by  fully 
saturating  lemon-juice  with  the  carbonate  of  potassa ;  or,  if  more 
agreeable  to  the  patient,  the  ordinary  lemonade  may  be  used.  In 
diarrhoea,  which  is  so  frequent  an  attendant  on  thrush,  some  such 
combination  as  the  following  may  be  used : 

R. — Hydrargyri  cum  creta,  gr.  ij ; 

Pulveris  opii,  . 

Pulveris  ipecacuanhse,  aa  gr.  j  ; 

Magnesiae  carbonatis,  gr.  xij.     M. 
Ft.  chart.  No.  xii. 

Of  these  powders,  the  infant  may  take  one,  mixed  in  molasses  or 
other  vehicle,  every  two  hours,  until  the  discharge  is  checked,  or 
until  the  twelve  are  taken.  In  diarrhoea  with  green  discharges  it 
may  be  sufficient  to  use  the  magnesia  alone  ;  or  lime-water,  which  is 
more  convenient  of  exhibition,  may  suffice  for  the  correction  of  the 


THE  APHTHA.  693 

acidity :  this  latter  can  be  rendered  palatable  by  adding  to  it  some 
of  the  aromatic  waters.  A  combination,  for  the  knowledge  of  which 
I  am  indebted  to  my  eminent  colleague  Prof.  Penrose,  and  which  it 
would  seem  could  scarcely  be  replaced  by  a  better,  is  as  follows  : 

R. — Bismuthi  subnitratis, 

Myristicse  pulveris,  aa  5ij  I 
Gretas  preparatse,  9ij; 
Syrupi  zingiberis,  5iss.     M.* 
Dose,  from  twenty-five  drops  to  a  teaspoonful,  according  to  age, 
repeated  every  two  hours. 

In  cases  associated  with  much  intestinal  disturbance,  it  will  in 
most  instances  be  found  satisfactory  practice  to  combine  laudanum 
or  paregoric  with  olive-  or  castor-oil,  administering  in  such  doses  as 
accord  with  the  age  of  the  patient.  A  child  one  year  of  age  may 
take  three  drops  of  laudanum  or  twenty  of  paregoric,  combined  with 
a  teaspoonful  of  the  oil ;  for  an  adult  a  dose  would  be  twenty-five  or 
thirty  drops  of  laudanum  to  a  tablespoonful  of  the  oil.  It  is  also 
found  useful  to  drink  freely  of  the  demulcent  waters,  marshmallow 
and  gum  arable  being  among  the  best  of  these.  In  debility, — and 
this  is  by  far  the  most  frequent  of  the  conditions, — combinations  of 
iron  and  bark,  conjoined  with  the  most  nutritious  articles  of  diet, 
will  be  found  indicated :  ferrated  elixir  of  cinchona  is  a  pleasant  and 
very  reliable  preparation,  and  is  freely  taken  by  children.  The  dose 
for  an  adult  is  one  teaspoonful,  repeated  three  or  four  times  a  day ; 
to  an  infant  a  year  old,  ten  drops  may  be  given. 

Concerning  the  diet,  if  the  patient  is  beyond  the  age  of  infancy, 
it  will  be  found  that  the  richest  food  is  most  advantageously  re- 
ceived ;  juicy  beef,  oysters,  malt  liquor,  wine,  etc.,  being  freely 
allowed.  In  the  infant,  the  character  of  the  milk  of  the  mother  is  to 
be  examined :  in  many  cases  it  will  be  found  needful  to  furnish  a 
different  nurse,  or,  otherwise,  wean  the  child.  Many  cases  of  per- 
sistent thrush  in  the  infant  have  quickly  disappeared  after  a  change 
of  nurses. 

Gangrasna  oris,  the  most  degenerative  and  destructive  of  the 
aphthae,  requires  the  most  persistent  vigor  in  the  treatment,  both  as 

*  The  author  is  assured  that  his  readers  will  recognize  the  obligation  he 
places  them  under  in  directing  attention  to  this  palatable  combination.  As 
a  medicine  for  the  ordinary  diarrhoea  of  summer,  both  in  the  infant  and  adult, 
it  will  seldom  be  found  to  disappoint  in  affording  the  desired  cure. 


694  ORAL  DISEASES  AND  SURGERY. 

regards  systemic  and  local  conditions.  Sulphate  of  quinia  and  the 
muriated  tincture  of  iron  are,  in  the  first  direction,  most  to  be  relied 
on.  This  condition  occurs  most  frequently  between  the  periods  of 
first  and  second  dentition,  and  is,  without  doubt,  more  .common  to 
the  miasmatic  than  to  other  regions,  excepting  always  the  location 
of  ill-kept  and  ill-ventilated  charities.  Gangraena  oris  may  have  a 
local  excitant,  but  it  is  never  without  a  constitutional  predisposition. 
It  may  commence  as  a  simple  sore,  gradually  degenerating,  or,  as  in 
carbuncle,  destruction  may  reside  in  the  primary  impression.  A 
common  form  of  sloughing  stomatitis  is  its  appearance  as  a  whitish 
or  ash-colored  eschar  situated  upon  the  gums,  lips,  or  cheeks.  This 
eschar  quickly  falls  out,  being  followed  by  degeneration  of  the  asso- 
ciate parts ;  the  breath  becomes  offensive,  the  saliva  flows  as  in 
ptyalism,  while,  to  add  to  the  discomfort,  the  ulcer  pours  out  an 
acrid,  corrosive  fluid,  which  not  only  excoriates  the  mouth,  but 
seems  to  provoke  the  extension  of  the  mortification.  If  not  checked, 
the  ulceration  extends  to  the  bone,  quickly  involving  it  in  the  gen- 
eral destruction,  and  bringing  on  the  condition  of  necrosis, — necrosis 
infantilis,  as  the  disease  is,  unfortunately,  so  frequently  compelled 
to  be  named. 

The  treatment  of  gangraena  oris  is  precisely  that  of  a  carbuncle. 
We  endeavor  to  circumscribe  the  action  by  sloughing  out  the  af- 
fected part  with  the  aid  of  caustic ;  this  accomplished,  we  stimulate 
the  general  system,  correct,  where  possible,  all  functional  disturb- 
ances, and  use  for  the  relief  of  the  local  sore  such  soothing  means 
as  seem  indicated. 


I 


CHAPTER    XXXV. 

HANULA. 

The  subject  of  ranula  is  one  easily  comprehended.  A  ranula  is 
the  analogue  of  the  sebaceous  tumor,  being  simply  a  tumor  of  re- 
tention, a  collection,  the  result  of  the  closure  of  a  tube  of  outlet. 
The  tumor  thus  designated  is  found  principally  beneath  the  tongue  ; 
it  is  a  swelling  varying  in  size  or  in  expression  according  to  the  cir- 
cumstances of  its  existence,  at  times  being  observed  when  not  larger 
than  a  pea,  at  others  so  great  in  bulk  as  to  throw  the  tongue  back 
into  the  fauces.  Ranulae  will  sometimes  be  met  with  which  fill  the 
whole  oral  cavity;  such  dimensions,  however,  are  uncommon. 

Recalling  the  anatomy  of  the  salivary  glands,  we  remember  that 
the  submaxillary,  situated  beneath  the  jaw,  has  the  outlet  for  its 
secretions  in  a  tube  opening  at  the  side  of  the  fraenum  linguas, — the 
duct  of  Wharton,  as  it  is  called.  The  lingual  gland  empties  itself 
on  the  same  line.  The  parotid,  by  its  tube,  the  duct  of  Steno,  opens 
upon  the  mucous  face  of  the  cheek  oppositC'the  superior  second  molar 
tooth.  While  patulous,  these  tubes  convey  into  the  mouth  the  secre- 
tions of  their  respective  glands,  and  thus  the  saliva,  passing  to  its 
recremental  purpose,  is  disposed  of. 

If  we  were  to  tie  or  otherwise  obstruct  one  of  these  tubes,  it 
would  be  natural  to  expect  that  the  secretion  accumulating  back  of 
the  ligature  would  expauJ  and  bulge  out  the  duct  into  the  form  of  a 
tumor.  This  is  really  the  very  simple  history  of  the  formation  of  a 
ranula. 

Ranula,  thus  provoked  and  thus  formed,  varies  as  much  in  appear- 
ance and  character  as  in  size.  In  one  case  it  will  look  and  feel 
almost  precisely  like  the  belly  of  a  frog,  the  enveloping  cyst  being 
thin  and  attenuated.  In  other  instances  the  walls  are  thick.  The 
contents  present  varying  characteristics,  being  watery,  or  semi-solid, 
or  solid,  even  to  the  hardness  of  stone,  as  illustrated  in  the  very  in- 
structive case  cited  in  the  chapter  on  Salivary  Calculus.  Commonly 
the  contents  consist  of  a  yellow,  albuminous-like  substance,  which, 
for  its  evacuation,  requires  pressure  upon  the  tumor  after  an  in- 
cision has  been  made. 

(695) 


696  ORAL  DISEASES  AND  SURGERY. 

A  ranula,  the  contents  of  which  are  watery,  implies,  as  a  rule, 
that  the  disease  has  been  of  short  existence,  the  fluid  being  simply 
the  secretion  from  the  gland  unchanged  in  character.  In  the  ranula 
of  semi-solid  consistence  an  explanation  is  found  in  the  partial 
absorption  of  the  more  fluid  portion,  leaving  an  inspissated  mass.  In 
the  solid  ranula  the  encystment  is  the  common  salivary  calculus, — 
being  precisely  the  same  as  is  found  upon  the  sides  of  the  teeth, 
excepting  in  the  absence  of  the  common  detritus  of  the  mouth.  Such 
a  ranula  will  be  found  to  be  of  longstanding:  absorption  of  the  watery 
portion  has  gone  on  until  what  remains  is  the  limy  portion  of  the 
secretion. 

A  thin  cyst  implies  a  rapidly-formed  tumor  unattended  by  vascular 
excitement,  the  envelope  being  a  simple  attenuation  of  the  walls  of 
the  duct  and  overlying  parts.  This  form  of  ranula  very  frequently 
ruptures,  and  thus  effects  a  self-cure.  Cysts,  thickened  and  hard, 
imply  tumors  of  slower  growth  and  the  association  of  vascular 
changes  resulting  in  the  effusion  within  the  cyst-wall,  and  the 
organization  of  a  greater  or  less  amount  of  lymph.  Cysts  thus 
thickened  may  compose  the  principal  bulk  of  ranulse,  the  cavities 
being  very  small  in  comparison. 

A  ranula  gives  trouble  from  its  bulk  and  location  alone,  seldom  or 
never  degenerating.  It  does  not  seem  true,  either,  that  harm  results 
to  digestion  from  the  loss  of  the  secretion,  such  loss,  indeed,  being 
more  apparent  than  real,  the  associate  glands  performing  excess  of 
work.  A  ranula  attaining  great  size  would  necessarily  intrude  upon 
all  the  surrounding  parts,  thereby  provoking  secondary  lesions  which 
might  very  well  prove  of  more  serious  character  and  consequence 
than  the  original  disease :  thus,  cases  are  on  record  where  the  teeth 
have  been  forced  from  their  sockets,  where  large  ulcers  have  been 
formed  against  the  inner  face  of  the  lower  jaw,  where  necrosis 
of  extensive  character  has  been  provoked,  etc. 

Treatment. — This,  in  principle,  consists  simply  in  opening  the 
tumor,  evacuating  its  contents,  and  so  conducting  the  cure  of  the 
wound  that  it  shall  not  entirely  close,  securing  and  preserving  in 
this  way  an  orifice  of  exit  for  the  secretion. 

In  the  rana,  or  frog-belly  tumor  (for  here  there  is  ranula  of  both 
sides),  it  is  found  sufficient  to  catch  up  with  the  tenaculum  or  forceps 
a  portion  of  the  sac,  and  with  the  scissors  or  bistoury  cut  it  off:  the 
edges  are  then  to  be  cauterized,  and  the  case  left  to  nature. 

In  the  thickened  cysts  such  an  operation  as  just  suggested  might 
not  be  easy  to  accomplish.     In  such  a  case  take  a  strand  of  ligature 


RANULA.  697 

wire  (silver  is  to  be  preferred),  double  it  upon  itself^  half  a  dozen 
times,  to  the  extent  of  the  supposed  thickness  of  the  sac  of  the 
tumor  to  be  operated  upon.  Take  next  the  continuation  of  the 
length  of  the  wire,  and  closely,  yet  spirally,  bind  with  it  the  thick- 
ness just  secured  by  the  half-dozen  reflections.  Next  take  a  curved 
needle,  and  thread  the  wire  to  it.  Now  pass  it  through  the  tumor, 
entering  at  the  centre.  When  the  thickened  part  of  the  wire — 
which  is  to  be  bulbed  by  a  perforated  shot  compressed  on  its  ex- 
tremity— is  brought  in  contact  with  the  cyst,  it  is  to  be  let  in  by  an 
incision  just  large  enough  to  allow  the  passage ;  pull  it  now  in,  until 
checked  by  the  shot ;  fix  the  needle-end  so  as  to  retain  the  thickened 
end  in  place,  and  the  operative  part  of  the  proceeding  is  completed. 

A  second  mode,  founded  on  the  same  principle  of  drainage,  con- 
sists in  taking  a  delicate  rubber  tube,  and,  after  cutting  through  its 
walls  a  number  of  outlets,  passing  it  through  the  tumor.  To  retain 
it  in  place,  the  extremities  are  tied  together,  having  an  opening 
made  between  the  ligature  and  the  tumor. 

If,  when  making  the  little  section  in  the  tumor  for  the  passage  of 
the  wire  or  tube,  the  contents  should  not  at  once  escape,  they  are 
to  be  pressed  or  syringed  out.  If  the  parts  seem  particularly  indo- 
lent, there  is  no  objection  to  the  introduction  of  a  stimulating  injec- 
tion. The  presence  of  the  drain  will,  however,  in  ordinary  cases 
prove  sufficiently  provocative  of  the  desired  action.  Iodine  in  tinc- 
ture may  be  used  externally  over  the  face  of  the  tumor. 

In  a  ranula  holding  a  calculus  within  the  cyst  nothing  is  to  be 
done  without  using  the  knife,  except,  indeed,  in  certain  occasional 
instances  where  the  orifice  of  the  duct  has  become  patulous  and  the 
stone  can  be  seen  or  felt.  In  these  cases  the  operator  may  succeed 
in  drilling  or  breaking  it  in  pieces,  and  thus  securing  its  removal. 
It  is  much  easier,  however,  even  here,  to  incise  down  to  the  stone, 
and  thus  take  it  away.  The  case  alluded  to  as  mentioned  in  the 
chapter  on  Salivary  Calculus  is  as  good  a  study  as  could  be  given 
in  the  direction. 

All  cysts  or  tumors  found  beneath  the  tongue  are  not,  however, 
to  be  esteemed  as  being  of  the  character  just  described.  Inflamma- 
tion of  the  sublingual  gland  is  not  unfrequently  met  with,  and  the 
tumefaction  is,  at  times,  so  considerable  as  to  very  closely  simulate 
ranula.  Cysts  within  the  substance  of  the  glands,  not  salivary  in 
character,  are  other  of  the  conditions  encountered,  and  these  more 
closely  simulate  the  ordinary  ranula  than  the  first,  particularly  when 
the  cyst  is  simple.  Papillary  indurations  are  sometimes  met  with 
in  the  same  situation. 


698  ORAL  DISEASES  AND  SURGERY. 

Lipoma  simulating  ranula  is  found  occasionally  referred  to.* 
Writers,  prominent  among  whom  is  M.  Marrant  Baker,  are  found, 
who  incline  to  doubt  the  common  relation  of  the  condition  with  the 

*  "  Lipoma  simulating  Eanula. — Mr.  F.  Churchill  exhibited  a  specimen 
of  lipoma  simulating  ranula.  He  said  this  tumor  was  removed  from  under 
the  tongue  of  an  old  man,  eighty-six  years  of  age.  The  specimen  is  unique, 
so  far  as  the  Society  is  concerned.  I  have  b6en  unable  to  find  in  the  Trans- 
actions  any  records  of  a  lipomatous  tumor  removed  from  this  situation,  and 
there  is  no  such  tumor  in  the  Museum  of  the  College  of  Surgeons.  Mr.  Liston 
refers  to  the  removal  of  fatty  tumors  under  the  tongue  in  his  work  on  Practical 
Surgery.  Mr.  Pollock  removed  a  fatty  tumor  from  below  the  jaw  of  a  lady 
forty  years  of  age,  enveloping  the  mylo-hyoid  muscle  ;  but  in  this  case  the  in- 
trinsic muscles  of  the  tongue  do  not  appear  to  have  been  encroached  upon  by 
the  tumor.  In  several  cases,  hardened,  putty-like  masses  have  been  removed 
from  a  ranular  cyst,  as  also  phosphatic  concretions.  During  the  last  session  of 
the  Society,  Mr.  Warren  Tay  exhibited  four  or  five  butter-like  masses,  which 
he  had  removed  from  a  ranular  cyst,  but  '  under  the  microscope  no  definite 
structure  could  be  detected  in  them.  Entangled  in  the  substance  composing 
the  masses  were  some  cells  and  portions  of  cells  looking  like  debris  of  epithe- 
lium.' Dr.  Meymott  Tidy,  after  a  careful  chemical  analysis,  'was  disposed 
to  regard  the  bulk  of  the  deposit  as  adipose.'  The  history  of  the  case  .was  as 
follows :  H.  T.,  aged  eighty-six,  was  admitted  to  the  "Westminster  General 
Dispensary,  under  the  care  of  my  colleague.  Dr.  Waite,  who  treated  him  for 
eczema  rubrum  of  the  leg.  After  consultation  with  Dr.  Waite  as  to  the  na- 
ture of  the  tumor  beneath  the  tongue,  supposing  it  to  be  a  ranula,  I  suggested 
that  it  should  be  removed  in  the  usual  way.  He  stated  that  on  several  occa- 
sions fluid  had  issued  from  the  tumor,  after  which  it  was  distinctly  smaller. 
The  incisive  teeth  in  the  lower  jaw  were  intact,  and  situated  just  behind  these 
was  a  movable  (apparently  pedunculated)  tumor,  about  the  size  of  a  walnut, 
covered  by  the  smooth,  glistening  mucous  membrane  of  the  floor  of  the  mouth. 
The  tumor  was  also,  in  part,  covered  by  the  sublingual  gland  ;  it  was  soft  and 
yielding,  and  I  was  under  the  impression  that  I  could  detect  fluctuation. 
The  distended  mucous  membrane  was  being  chafed  by  contact  with  the  sharp 
edge  of  the  teeth  during  mastication.  The  old  man  had  noticed  the  swelling 
for  twenty-two  years.  It  had  gradually  increased  up  to  the  present  time. 
During  the  past  twelve  months,  however,  it  had  given  him  pain,  in  conse- 
quence of  chafing  against  the  teeth  ;  he  much  feared  that  it  was  a  cancer. 
From  its  size  it  had  also  interfered  with  mastication,  and  acted  as  a  serious 
impediment  to  his  speech.  Having  removed  a  portion  of  the  anterior  wall 
of  the  tumor,  I  proceeded  to  turn  out  the  contents,  but  found,  underlying  the 
mucous  membrane,  a  bright,  glistening  mass,  resembling  a  cyst-wall ;  this 
was  seized  with  a  pair  of  clutch-forceps  and  drawn  forward,  a  small  portion 
of  it  being  removed,  but  still  no  fluid  escaped.  I  proceeded  then  to  separate 
the  adhesions  to  the  mucous  membrane  with  the  spoon-end  of  a  director,  but 
the  deep  connections  were  too  firm  to  separate  in  this  way ;  the  finger  also 
failed  to  enucleate  the  mass.     The  tumor  was  forcibly  drawn  forward,  and 


RANULA. 


699 


Fia.  2J0. 


salivary  ducts,  but  upon  such  premises,  as  must  appear  to  any  one 
who  shall  see  much  of  the  condition,  that  the  arguments  advanced 
carry  no  weight :  the  true  ranulse  arise  from  salivary  lesions  influ- 
encing the  relations  of  the  discharge :  tumors  of  kindred  position 
may  have  the  signification  of  muciparous  cysts,  or  may  be  expressive 
of  a  systemic  vice ;  because  a  tumor  is  beneath  the  tongue  it  is  not 
necessarily  a  ranula. 

Ranulse  are  found  superficially  seated,  or  deep,  according  to  the 
part  affected  and  the  location  of  the  lesion : 
thus,  ranulae  associated  with  the  tubal  outlets 
of  the  sublingual  gland  are  always  entirely 
superficial,  because  the  part  affected  is  cov- 
ered only  by  the  mucous  membrane.  Obstruc- 
tion of  the  duct  of  Wharton  at  its  orifioo 
yields  also  a  superficial  tumor,  lying  as  it 
does  between  the  mucous  membrane  and 
the  mylo-hyoid  muscle ;  occurring,  howevei', 
beneath  this  muscle,  the  tumor  resulting  is 
deep-seated. 

Ranulse  are  of  temporary  or  permanent 
signification:  thus,  where  only  a  limited  ob- 
struction exists,  a  tumor  may  form  suddenly 
during  the  excess  of  secretion  at  periods  of 
mastication,  to  drain  gradually  away  as  the 
superexcitation  passes  off.  Or  cases  are  met 
with  where,  as  the  result  of  accidental  inflam- 
matory conditions,  the  outlets  become  obstructed  from  neighboring 
exudates,  the  tumor  disappearing  as  the  exudates  are  absorbed. 

The  existence  of  true  ranula  does  not  necessarily  imply  that  the 
tube  afi"ected  is  absolutely  closed:  a  ranula  may  exist  where  obser- 


Superficial  Ranula,  showing 
seton  introduced.* 


these  deep  attachments  cautiously  divided  with  the  knife.  In  this  way  the 
tumor,  which  was  lobulated,  and  enveloping  (probably)  the  genio-hyoglossi 
muscles,  was  removed.  Exploring  the  cavity  afterwards,  I  could  feel  the 
sharp  borders  of  the  vertical  muscles,  and  I  was  satisfied  that  the  growth  had 
been  entirely  removed.  There  was  very  little  hemorrhage  after  the  operation, 
and  the  cavity  had  completely  closed  in  the  course  of  a  week." — Proceedings 
of  the  Pathological  Society. 

*  This  is  but  a  single  expression  of  the  superficial  ranulse.  One  treated  this 
very  day  of  writing  by  the  author — being  a  double  tumor — presented  the  ap- 
pearance of  the  whole  floor  of  the  mouth  being  raised  on  a  level  witli  the 
teeth. 


700 


ORAL  DISEASES  AND  SUBGERT. 


vation  discovers  the  canal  patulous  and  the  secretion  discharging; 
here  an  explanation  is  found  in  well-known  similar  stricture  as  met 
with  in  the  relation  of  the  bladder  and  its  urethral  canal,  urine  con- 
stantly dribbling  from  the  meatus,  yet  the  patient  suffering  from 
retention ;  or,  again,  a  probe  may  be  passed  with  all  ease  into  the 
orifice  of  a  canal,  yet  a  true  tumor  of  retention  exist, — here,  as 
referred  to,  a  stricture  being  deep-seated. 

Cases  of  hygrometric  or  bursal  tumors  are  to  be  met  with  occa- 
sionally upon  the  neck,  which  mayor  may  not  be  ranular.  No  more 
instructive  case  in  such  direction  has  ever  fallen  under  my  own 
observation  than  that  described  in  the  chapter  on  Salivary  Fistula. 
A  tumor  precisely  similar  in  appearance  to  this  particular  one,  but 
situated  beneath  the  right  submaxillary  gland,  was,  at  a  late  clinic 
of  the  University  Hospital,  dissected  by  my  colleague  Prof  Agnew 
from  the  neck  of  an  infant ;  but  here  no  association  with  the  gland 
was  discoverable :  also,  at  the  same  clinic,  a  tumor  of  similar  loca- 
tion and  appearance  from  the  neck  of  an  adult,  with  similar  absence 
of  discoverable  relation.      Such   tumors   have  the  sigrnification  of 


Flg.  241. 


Deep-seated  Ranula. 


engorged  and  enlarged  bursse,  or  at  least  are  to  be  so  treated,  and  are 
the  analogue  to  what  is  so  familiar  as  the  "  housemaid's  knee." 


RANULA.  701 

The  salivary  glands  themselves  are  occasionally  the  seat  of  in- 
flammatory swellings,  which  are  quite  as  apt  to  become  indolent  as 
to  resolve.  I  have  within  my  own  observation  several  of  these  cases, 
and  sometimes  have  been  six  months  in  reducing  such  an  indura- 
tion. The  submaxillary,  however,  seems  to  be  the  gland  most  dis- 
posed to  take  on  such  conditions,  and  the  tumefaction  thus  produced 
is  without  rather  than  within  the  mouth,  although  it  not  unfrequently 
happens  that  it  is  first  observed  by  the  patient  as  a  hard  body  on  the 
inner  side  of  the  jaw. 

Another  form  of  tumor  which  may  here  be  alluded  to  is  found 
in  the  submaxillary  triangle. 

In  dissecting  down  to  the  submaxillary  gland,  there  will  be  ex- 
posed, when  the  body  is  uncovered  by  removing  the  superficial  leaf 
of  the  triangular  fascia,  two  lymphatic  glands.  These  glands  are 
very  apt  to  indurate,  forming  sometimes  a  tumor  of  considerable 
size.  I  have  met  with  them  as  large  as  a  walnut.  It  is  most  com- 
mon to  mistake  such  indurations  for  hypertrophy  of  the  submaxil- 
lary itself  Two  diagnostic  signs  distinguish  the  first:  they  ar.e  not 
triangular,  and  they  are  not  so  solidly  fixed  as  when  the  chief  gland 
is  the  seat  of  the  enlargement. 

A  case  of  glandular  tumor,  very  suggestive  as  a  study,  is  recorded 
in  Bell's  "Principles  of  Surgery."  The  attention  of  the  reader  is 
directed  to  it : 

The  case  was  that  of  "  a  young  woman  of  Berwick,  whose  native 
peculiarity  of  accent  had  received  a  singular  aggravation  by  such  an 
uncouth  obliquity  and  imperfect  motion  of  the  tongue  as  conveyed 
the  notion  of  her  attempting  to  chew  and  turn  each  vocable  with  her 
tongue  before  she  proceeded  to  swallow  it,  in  place  of  uttering  it. 

"  This  was  produced  by  a  tumor  of  very  great  size,  and  of  an 
appearance  so  peculiar  as  plainly  to  denote  its  character.  It  con- 
sisted in  a  vast  collection  of  matter  in  the  sublingual  gland ;  and  as 
that  gland  is  covered  by  the  whole  thickness  of  the  tongue  within, 
and  by  the  mylo-hyoidei  muscles  without,  and  bounded  by  the  line 
of  the  jaw-bone,  it  had  the  following  singularities  of  character.  It 
could  not  be  distinguished  as  a  tumor,  but  bad  rather  the  appear- 
ance of  a  general  swelling  of  the  lower  part  of  the  face,  jaw,  and 
neck,  such  as  often  accompanies  severe  toothache  or  mumps.  Upon 
laying  the  hand  upon  the  outside  of  the  neck,  below  the  lower  jaw- 
bone, the  whole  hand  was  filled  with  a  swelling,  apparently  solid, 
but  so  little  convex  or  circumscribed  as  to  resemble  in  no  degree  the 
tumor  of  any  particular  gland,  and  yet  so  limited  and  so  firm  as  not 


702  OBAL  DISEASES  AND   SURGERY. 

at  all  to  resemble  the  general  tumefaction  proceeding  from  toothache. 
Upon  introducing  the  finger  into  the  mouth,  you  found  the  tongue 
raised,  turned  edge  uppermost,  and  pressed  entirely  toward  the  left 
side  of  the  mouth,  the  external  tumor  being  upon  the  right  side. 
Upon  pressing  the  fingers  very  firmly  down  by  the  side  of  the 
tongue,  and  reaching  from  without,  you  could  sensibly  perceive  not 
so  properly  a  fluctuation  as  an  elasticity,  which  implied  the  presence 
of  a  fluid  ;  the  tumor  seemed  elastic  like  a  football,  but  with  a  degree 
of  tension  which  made  it  seem  almost  solid.  It  was  by  comparing 
a  variety  of  circumstances,  especially  the  original  place  and  slow 
growth  of  the  tumor,  that  I  confidently  referred  it  to  the  sublingual 
gland.  In  this  I  had  the  advantage  of  the  surgeon  under  whose 
particular  care  she  was  ;  but  I  did  him  the  justice  to  send  her  back 
to  him,  again  and  again,  expressing  my  opinion  and  my  wish  at  the 
same  time  that  he  should  do  whatever  he  might  suppose  right.  By 
good  fortune,  she  called  upon  me  the  day  she  was  to  return  home, 
nothing  being  as  yet  done  to  the  tumor,  but  supplied  with  abundance 
of  blisters  and  plasters  to  apply  at  a  fit  opportunity  to  her  throat.  I 
felt  now  that  professional  ceremonies  should  give  way  to  essential 
charities.  I  placed  her  in  a  chair,  and  almost  without  her  conscious- 
ness— at  least  before  she  was  aware — I  struck  a  fine  bleeding-lancet 
deep  into  the  tumor  by  the  side  of  the  fraenum  of  the  tongue,  when, 
from  the  firm  compression  of  the  surrounding  parts,  the  matter, 
though  too  gross  to  pass  freely  thi'ough  such  an  opening,  was 
spewed  out  from  the  orifice,  in  a  manner  expressly  resembling  that 
in  which  yellow  paint  is  squeezed  out  from  the  bladder  upon  a 
painter's  pallet.  It  was  of  a  deep  saffron  color,  thicker  than  mustard, 
mixed  like  gruel  with  seed-like  particles,  and  exceedingly  fetid.  I 
knew  that  the  tumor  was  not  emptied,  though  the  outward  swelling 
was  almost  gone ;  but  I  also  knew  that  though  I  should  not  enlarge 
the  opening,  the  second  secretion  from  the  surface  of  the  sac,  which 
is  in  all  cases  thin,  would  dilute  and  wash  out  whatever  viscid 
matter  remained ;  and  when  she  saw  how  suddenly  my  prognostic 
was  fulfilled,  she  expressed  a  perfect  confidence  in  whatever  I  pre- 
dicted, and  a  perfect  willingness  to  submit  cheerfully  to  whatever  1 
proposed  to  do.  Next  day  I  introduced  the  point  of  a  probe-pointed 
bistoury  into  the  orifice  made  by  the  lancet;  and,  knowing  that  the 
lingual  artery  lies  on  a  lower  level,  imbedded  among  the  muscles, 
and  running  along  the  lower  surface  of  the  tumor,  while  I  had  over 
the  point  and  blade  of  my  bistoury  nothing  but  the  inside  membrane 
of  the  mouth,  much  thickened,  I  ran  it  fearlessly  and  at  one  stroke. 


RANULA.  703 

as  the  less  painful  way,  along  the  whole  length  of  the  tumor,  when 
the  thickest  of  the  yellow  mucus  flowed  freely,  or  was  raked  out  with 
the  points  of  the  fingers  and  the  handle  of  the  bistoury;  and  the 
tongue,  descended  now  to  its  natural  level,  was  in  a  capacity  once 
more  of  delivering  the  peculiar  dialect  of  her  native  city  in  all  its 
purity. 

"  So  tense  and  apparently  solid  was  this  tumor,  in  consequence  of 
the  compression  by  so  many  surrounding  muscles,  that  her  surgeon 
mistook  it  for  a  solid  and  strumous  swelling.  I  reckoned  that  in 
this,  as  in  all  cases  of  sacculated  tumor,  the  second  secretion,  which 
was  thinner,  would  wash  out  the  thicker  mucus,  and  I  was  not  de- 
ceived ;  but  she  left  me  too  early  for  me  to  witness  the  obliteration 
of  the  sac. 

"I  find  it,  in  all  such  cases,  a  matter  of  some  importance,  es- 
pecially in  a  girl,  to  anticipate  the  outward  suppuration  of  any  sac- 
culated tumor,  by  puncturing  it,  though  to  a  great  depth  within  the 
mouth  and  under  the  tongue,  and  equally  necessary  to  be  at  pains 
in  preserving  the  opening  and  obliterating  the  sac  :  a  slight  miscon* 
duct  in  this  respect  occasions  much  distress  to  the  patient  and  much 
superfluous  labor  to  the  surgeon." 

Illustrations. — In  his  own  practice  the  author  has  treated  quite 
his  share  of  cases  in  this  direction,  having  had  as  many  as  three  at 
a  single  clinic.  True  uncomplicated  ranula  he  has  almost  always 
been  able  to  cure,  without  trouble  or  difficulty,  by  the  use  of  the 
drainage  seton.  Fig.  240  exhibits  such  a  seton  applied.  As  studies, 
however,  it  may  not  be  amiss  to  introduce  a  few  illustrative  ex- 
amples; and,  as  in  the  practice  of  others  he  finds  all  that  seems 
necessary,  he  saves  himself  the  trouble  of  writing  out  examples  of 
his  own  by  selecting  from  other  sources. 

"  Ranula. — Operation  by  Dr.  Hamilton.  P.  R.  Cortelyou,  House 
Surgeon. 

"Dec.  13,  1867.  R.,  of  N.,  aged  sixteen  years,  private  patient, 
admitted  to  Bellevue  under  Dr.  Hamilton's  care. 

"  Soon  after  birth  his  father  noticed  a  swelling  under  his  chin, 
near  the  median  line,  which  has  continued  to  increase  ever  since. 
Now  the  size  of  a  large  orange,  nearly  in  the  centre,  but  inclining  a 
little  to  the  right  side.  It  is  not  painful  or  tender;  its  surface  is 
smooth  and  elastic.  On  exploration  it  was  found  to  contain  a  thin 
yellowish  fluid. 

"  Examining  within  the  mouth,  it  was  found  to  have  lifted  the 
tongue  considerably;  but  its  walls  did  not  present  the  translucent 


704  ORAL  DISEASES  AND   SUBGERY. 

appearance  sometimes  seen  in  ranula,  nor  could  it  be  decided  posi- 
tively whether  the  orifices  of  the  ducts  on  the  right  side  were  still 
open.  It  became  a  question  what  was  the  source  of  this  enlarge- 
ment or  tumor. 

"  The  term  '  ranula'  has  been  applied  by  some  surgeons  to  obstruc- 
tions of  the  sublingual  ducts,  by  others  to  obstructions  of  the  sub- 
maxillary ducts,  and  by  most  surgeons  to  obstructions  of  either  the 
one  or  the  other  indifferently.  Certain  writers,  also,  have  extended 
the  term  to  all  encysted  tumors  in  this  region,  whether  occurring  in 
the  areolar  tissue  or  in  muciparous  glands,  which  present  a  common 
external  appearance  like  the  throat  of  a  frog. 

"  It  was  not  very  clear  from  which  of  these  several  sources  this 
tumor  had  originated.  It  was  decided,  therefore,  to  proceed  as  if  it 
were  an  obstructed  duct.  Accordingly,  Dr.  Hamilton  made  a  small 
incision  into  the  tumor  beside  the  tongue,  on  the  right  side,  avoiding 
carefully  the  ranine  artery.  This  opening  was  at  once  enlarged  by 
introducing  a  pair  of  bullet  forceps  and  expanding  them,  so  as  to 
tear  the  wound  larger.  The  sac  was  emptied,  and  a  piece  of  lami- 
naria  digitata  introduced.  On  the  third  day  considerable  inflamma- 
tion existed,  extending  to  the  root  of  the  tongue  and  side  of  the 
face.  There  had  been  also,  up  to  this  time,  a  constant  but  slight 
hemorrhage.  Both  the  swelling  and  bleeding  abated  from  this  time. 
The  contents  of  the  sac  were  examined  under  the  microscope,  but 
not  with  sufficient  care  to  determine  their  character. 

"Feb.  1,  1868,  nearly  two  months  after  the  operation,  the  father 
reports  that  the  sac  has  almost  disappeared.  A  little  pus  continues 
to  discharge,  and  there  is  no  tenderness  or  swelling.  The  laminaria 
is  taken  out  daily,  and  replaced  with  ease.  It  is  probable  that  the 
complete  cure  will  not  take  place  under  several  mouths. 

"Dr.  Hamilton  mentioned  that  a  ranula  was  said  to  form  occa- 
sionally in  a  bursa  outside  of  the  genio-hyoid  muscle;  but  he  had 
searched  for  this  bursa  and  could  not  find  it." 

'^  Swelling  of  Submaxillary  Gland  from  Inflammatory  Obstruc- 
tion of  its  Duct. — Charles  D.  Hoyt,  of  Middlesex,  Yates  county, 
called  upon  Dr.  Hamilton,  December  29,  1846,  with  a  moderate  en- 
largement of  the  right  submaxillary  gland,  it  being  apparently,  as 
felt  beneath  the  jaw,  of  the  size  of  a  large  Lima  bean.  He  stated 
that  this  enlargement  occurred  about  one  week  before,  while  eating 
his  breakfast,  and  that  in  five  minutes  it  attained  the  size  of  a 
'  walnut  with  its  bark  on,'  and  that  it  prevented  his   opening  his 


RANULA.  705 

mouth  freely.     After  leaving  the  table  he  rubbed  it  for  sorae  time, 
and  in  half  an  hour  it  was  reduced  to  its  present  size. 

"  From  that  time  the  same  enlargement  occurred  every  time  he 
ate,  and  without  any  reference  to  what  he  ate.  It  enlarged  most, 
however,  while  eating  his  first  meal  in  the  morning.  By  rubbing 
alone  could  it  be  reduced.  Chewing  tobacco  seemed  rather  to 
diminish  than  to  increase  its  size.  It  was  not  tender,  nor  red,  but 
when  enlarged  to  its  utmost  it  caused  a  severe  pain,  which  extended 
to  his  ear. 

"  Tincture  of  iodine  externally  was  first  employed  by  Dr.  H.  ; 
but,  no  result  being  obtained,  he  directed  him  to  take  a  full  dose  of 
Epsom  salts.  This  had  the  desired  effect.  The  enlargement  dis- 
appeared very  quickly,  and  did  not  return." 

"  Obstruction  of  both  Submaxillary  Ducts. — December  17,  1847, 
John  C.  Lj^ons,  aged  twenty,  Benton  Centre,  Yates  county,  con- 
sulted Dr.  H.  He  stated  that  in  the  latter  part  of  July,  while 
harvesting,  the  weather  being  very  warm,  he  discovered  in  the 
morning  a  soreness  under  his  tongue  upon  the  left  side,  and  before 
night  he  found  there  was  a  tumor  at  this  point.  It  was  oblong  and 
only  about  half  an  inch  in  length.  His  physician.  Dr.  Wolcoit, 
opened  it  the  following  day,  and  it  discharged  a  glairy  matter. 
Since  then  it  had  been  opened  four  times  ;  but,  a  few  days  before 
calling  on  Dr.  H.,  he  discovered  that  there  was  a  swelling  on  the 
opposite  side,  externally,  in  the  region  of  the  submaxillary  gland. 
When  seen  by  Dr.  H.  the  gland  was  of  the  size  of  a  pullet's  egg, 
oblong,  not  painful  or  tender.  It  was  increasing  in  size,  but  he 
noticed  that  it  was  larger  in  cold  and  damp  weather.  His  health 
was  good.  He  was  advised  to  submit  to  a  low  diet,  take  physic,  and 
apply  externally  the  tincture  of  iodine.  He  was  never  seen  again, 
and  the  result  is  not  known.  During  the  winter  of  l5<47  and  '48 
two  similar  cases  of  enlargement  of  the  submaxillary  gland  were 
presented  in  Dr.  Hamilton's  Surgical  Clinic,  at  the  Buffalo  Medical 
College,  one  of  which  had  resulted  in  an  external  salivary  fistula. 

"  In  a  recent  report  of  one  of  Professor  Jarjavay's  clinics,  copied 
into  the  number  of  the  Gazette  des  Hopitaux  of  November  23, 
1867,  similar  enlargements  of  the  submaxillary  gland  are  mentioned 
as  occurring  in  connection  with  obstructions  of  Wharton's  duct ; 
but  he  restricts  the  application  of  the  term  ranula  to  obstruction  of 
some  one  of  the  twenty-eight  or  thirty  excretory  ducts  of  the  sub- 
lingual gland." 

Ranula. — In  one  of  a  series  of  interesting  papers  on  "Anatomy 

45 


706  ORAL  DISEASES  AND   SUBGERY. 

in  its  Relations  with  Medicine  and  Surgery,"  Professor  D.  Hayes 
Agnew  makes  the  following  remarks  on  this  subject:  "A  tumor  is 
met  with  beneath  the  end  of  the  tongue,  rising  from  the  floor  of  the 
mouth,  to  which  the  name  ranula  has  been  applied.  It  involves 
the  ducts  of  the  sublingual  glands,  the  excretory  orifices  of  which 
here  open.  These  become  obstructed  by  some  substance,  either 
mechanical  or  inflammatory,  the  secretion  accumulates  behind,  dis- 
tending thera  finally  into  a  semi-transparent  tumor.  Sometimes 
they  are  found  to  be  firm  and  resisting  in  the  texture.  In  such 
cases  the  distention  has  provoked  an  inflammatory  exudation  and 
its  organization  into  fibrous  tissue.  The  transparency  will  depend 
upon  the  attenuation  of  the  mucous  membrane.  The  san)e  morbid 
condition  may  be  present  in  a  very  limited  degree,  confined  even  to 
a  single  duct,  so  as  to  resemble  a  little  vesicle.  The  cure  of  such 
can  rarely  be  accomplished  by  puncture  and  evacuation  of  the  con- 
tents:  the  wound  you  make  will  soon  heal,  and,  as  the  duct  or  ducts 
are  not  restored  to  a  previous  condition,  the  swelling  will  be  repro- 
duced. No  treatment  short  of  that  which  contemplates  the  destruc- 
tion of  the  glandular  tissue  will  prove  effectual.  This  is  best  attained 
either  by  injection  or  excision;  the  latter  I  think  the  preferable, 
which  is  readily  done  by  including  the  mass  within  two  elliptical 
incisions,  and  then  allowing  the  wound  to  heal  by  granulation  or 
stitching  the  edges  together  with  the  finest  silver  wire.  If  it  be  a 
small  cyst,  after  clipping  it  away,  the  point  of  a  stick  of  caustic  may 
be  carried  into  the  wound  for  a  moment  or  so. 

"Another  tumor  is 'found  in  this  same  locality,  and  which  is  pro- 
duced by  a  salivary  calculus  becoming  arrested  near  the  outlet  of 
the  submaxillary  duct;  and,  last,  another  variety  of  tumor,  which  I 
am  disposed  to  believe  is  rare,  and  being  connected  with  the  under 
surface  of  the  top  of  the  tongue,  rather  than  the  floor  of  the  mouth, 
must  be  referred  to  the  cluster  of  glands  there  situated.  The  sides 
of  the  tongue  may  be  bound  down  by  cicatricial  tissue,  so  as  to  inter- 
fere with  its  proper  functional  movements.  Sliould  a  nerve-filament 
happen  to  be  included,  it  may  give  rise  to  a  very  painful  condition. 
This  is  best  remedied  by  incisions  or  exsection  of  the  diseased  struc- 
ture." 

Lately,  at  the  Imperial  Society  of  Surgeons  there  was  exhibited 
by  M.  Paulet  two  salivary  calculi  found  by  him  in  Wharton's  duct. 
In  connection  with  the  presentation  was  reported  the  unique  fact — 
for  such  it  was  thought  to  be — that  the  submaxillary  glands  of  both 
sides  were  found  stuffed  with  calculi.     M.  Pana,  however,  presented 


RANULA.  707 

at  the  same  meeting  a  single  calculus  taken  by  excision  from  tin's 
gland.* 

Eanula  treated  by  Mechanical  Pressure. — "Nearly  seven  years 
ago,"  says  Dr.  Wm.  Macdonald,  "J.  F.,  aged  twenty-two  years,  and 

residing  in  M Street,  in  this  city,  consulted  me  in  consequence 

of  being  much  distressed  with  a  ranula,  or  a  large  tumor  under  her 
tongue,  arising  from  nn  accumulation  of  saliva  and  mucus  in  the 
ducts  of  the  sublingual  gland.  For  two  years  after  the  period  this 
person  consulted  me,  she  was  attended  both  by  my  professional 
friends  and  myself,  and  that  without  success.  During'  these  two 
years  that  this  patient  was  under  the  surgical  and  medical  treatment 
both  of  my  medical  friends  and  myself,  the  following  methods  of 
cure  were  adopted  in  succession :  the  ranula  was  very  often  opened 
with  a  lancet,  and  injections  of  rose-water  and  sulphate  of  zinc  (five 
grains  of  the  sulphate  to  the  ounce  of  rose-water)  injected  by  means 
of  a  syringe,  night  and  morning,  into  the  cavity  of  the  emptied  ranula. 
Occasionally,  when  the  ranula  burst  of  its  own  accord,  and  left  an 
ulcer,  considerable  portions  of  the  sublingual  gland  were  dissected 
out ;  and  on  one  occasion  the  actual  cautery  was  proposed  to  be 
employed  ;  but  the  patient  would  not  consent  to  the  employment  of 
this  method  of  treatment.  During  the  two  years  the  patient  was 
under  treatment  she  took  occasionally  tonics  and  alteratives,  to- 
gether with  laxatives,  as  the  nature  of  her  case  seemed  to  require, 
but  without  any  good  effect. 

"In  these  critical  circumstances  it  occurred  to  me,  about  five 
years  ago,  that,  if  the  fluid  contained  in  the  ranula  were  completely 
evacuated,  the  employment  of  pressure  over  the  tumor  might  cause 
adhesion  of  almost  all  the  internal  surfaces  of  the  tumor,  except  a 
fistulous  aperture  or  apertures,  analogous  to  the  sublingual  duct, 
through  which  the  saliva  would  necessarily  flow,  and  by  necessary 
consequence  a  radical  cure  would  be  produced,  provided  that  a  per- 
manent adhesion  of  both  surfaces  of  the  ranula  could  be  eS'ected. 

"  In  order  to  produce  such  a  result,  I  proceeded  to  perform  the 
following  operation.  (I  must  remark  that  the  size  of  the  tumor  at 
this  period  was  such  as  to  preclude  the  possibility  of  swallowing 
any  fluid  or  solid  kind  of  food.)  I  introduced  a  bent  needle,  armed 
with  a  ligature,  into  the  ranula,  with  the  view  of  enabling  me  to 
render  the  tumor  steady  while  I  was  opening  it  with  the  lancet,  and 
also  in  order  to  direct  me  afterward  in  injecting  the  ranula ;  this 

*  See  chapter  on  Salivary  Calculus. 


708  ORAL  DISEASES  AND   SURGERY. 

being  done,  I  procured  a  common  musket-ball  of  lead,  a  little  flat- 
tened, and  having  a  perforation  through  it,  and  through  this  per- 
foration in  the  bullet  I  introduced  a  yard  or  so  of  common  tape, 
which  was  loosely  tied  around  the  neck  of  the  patient,  while  the 
bullet  remained  in  the  patient's  mouth  and  pressed  by  gravitation 
upon  the  upper  covering  of  the  ranula.  It  is  obvious  that  the  tape 
fixed  to  the  bullet  served  only  the  purpose  of  preventing  the  patient 
from  swallowing  the  bullet  while  it  remained  in  her  mouth.  The 
bullet  thus  kept  in  the  patient's  mouth  night  and  day  for  two  weeks 
produced  union  by  inflammation  (caused  by  mechanical  pressure)  of 
both  surfaces  of  the  ranula,  except  two  fistulous  apertures  analogous 
to  sublingual  ducts,  through  which  saliva  has  flowed  on  each  side  of 
the  fraenum  of  the  tongue  ever  since  ;  and  this  patient  has  happily 
had  no  return  of  her  troublesome  complaint  from  that  period  to  this 
date.  Now,  as  nearl}'^  five  years  have  elapsed  since  the  cure  of  the 
ranula,  we  may  hope  that  the  disease  will  not  again  return." 

Carcinoma  is  a  condition  sometimes  met  with  associated  with  the 
floor  of  the  mouth  ;  when  the  disease  is  situated  in  the  sublingual 
gland  it  is,  without  confusion,  to  be  distinguished  from  either  lipoma 
or  ranula.  A  lipoma  affords  to  the  touch  the  sense  of  contact  with 
fatty  tissue.  A  ranula,  however  thick  its  walls, — except  in  the  case 
of  the  encysted  calculus, — may  be  recognized,  by  the  employment  of 
the  exploring  needle,  to  be  a  cyst.  A  cancerous  tumor,  especially 
when  of  limited  size,  has  an  expression  of  solidity  pertaining  to 
neither  of  the  first  two,  while  associated  with  it  is  the  specific  pain, 
absent  in  the  others.  Induration  and  enlargement  of  this  gland 
when  associated  with  epithelioma  of  surrounding  parts  would  of 
course  have  explanation  in  the  association.* 

*  See  Seirrhus  of  Tongue  ;  also  chapter  on  Tumors. 


I 


CHAPTER    XXXYI. 


NEURALGIA. 


The  term  neuralgia  is  from  the  Greek  roots  veupov,  a  "nerve," 
and  aXyoq,  "pain."  It  signifies  a  condition,  or  an  efifect,  and  not  a 
cause ;  or,  if  this  definition  is  not  absolutely  a  correct  one,  the  excep- 
tions to  the  rule  it  would  form  are,  I  am  convinced,  exceedingly 
rare.  For  such  reasons  it  is,  as  commonly  employed,  a  very  decep- 
tive term,  expressing  a  condition  about  as  definitely  as  the  term  sup- 
puration would  convey  an  idea  of  the  phenomena  of  inflammation. 

Neuralgia,  as  the  word  has  been  made  to  have  definite  applica- 
tion, refers  to  paroxysmal  pains,  localized  or  metastatic,  presenting 
no  manifestation  of  any  lesion  at  the  seat  of  pain  outside  of  the  single 
phenomenon. 

The  pains  of  neuralgia  are  mostly,  although  not  exclusively,  acute 
in  character,  are  confined  to  the  tract  or  to  the  periphery  of  a  certain 
nerve,  remit,  or  more  commonly  fully  intermit,  and  are  only  accom- 
panied with  tenderness  of  the  part  involved  when  an  accidental  asso- 
ciate lesion  may  exist,  or  when  an  irritation  is  so  severe  or  has  been 
so  long  continued  as  to  have  reacted  on  the  neighboring  vascular 
system. 

When,  then,  a  practitioner  has  his  attention  directed  to  a  seat  of 
pain  without  apparent  lesion,  the  matter  of  first  importance  is  an 
appreciation  of  its  cause.  To  say  that  such  a  one  has  neuralgia, 
and  to  treat  him  with  nervines,  is  to  say  just  nothing,  and  to  do 
nothing,  except  indeed  by  accident.  A  first  duty  is  to  search  for  a 
cause,  and,  if  discoverable,  remove  it,  if  that  be  possible.  Now,  these 
causes  of  neuralgia  are,  as  I  shall  show  further  on,  sometimes  very 
evident,  and  very  easy  of  removal ;  and  it  will  be  seen  from  the  illus- 
trations offered  that  one,  from  lack  of  observation,  may  utterly  fail  in 
giving  a  relief  very  easily  and  naturally  afforded  by  another. 

Rheumatism  and  neuralgia  are  frequently  confounded ;  but  how 
do  the  conditions  disagree?  Rheumatism  is  always  accompanied 
with  vascular  perversion ;  the  pain  is  not  distinctly  localized,  but  is 

(t09) 


710  ORAL  DISEASES  AND   SURGEBY. 

diffused  over  a  part  involved  ;  it  is  a  soreness,  as  a  general  thing, 
rather  than  a  sharp,  acute,  concentrated  pain.  Movement  aggra- 
vates this  Soreness,  changes  in  temperature  afifect  it ;  it  is  not  parox- 
ysmal, although  it  may  be,  and  generally  is,  remitting;  in  short,  it 
has  a  history,  and  this  history  is  not  difficult  to  read. 

Gout  is  another  constitutional  condition  occasionally  mistaken  for 
neuralgia;  but  such  a  mistake  should  not  occur,  for  here,  too,  is  a 
history.  Gout  occurs  in  the  high,  indolent  liver;  it  is  decidedly 
inflammatory  in  its  local  manifestations.  It  attacks  in  preference 
the  small  joints  ;  it  is  accompanied  by  oedema,  by  congestion,  and 
by  enlargement  of  the  veins;  if  it  is  metastatic,  the  seat  of  transfer 
presents  like  vascular  phenomena  with  the  original  inflammation. 

But  is  there  not  a  condition — a  disease — which  is,  or  might  be, 
termed  neuralgia  ?* — as,  for  example,  gout  is  a  disease  with  an  indi- 
viduality, or  rheumatism  is  a  disease.  If,  without  being  influenced 
by  other  than  my  own  observations,  I  were  to  answer  this  question, 
I  should  incline  to  say  there  is  not;  and  my  reasons  for  the  denial 
would  lie  in  the  fact  that  I  have  in  one  way  or  another  become  con- 
versant with  so  many  cases  which  have  stubbornly  resisted  a  long 
course  of  treatment  founded  on  an  abstract  neuralgic  theory,  but 
which  have  rapidly  and  readily  yielded  on  the  discovery  and  re- 
moval of  some  true  lesion  of  which  the  pain  was  simply  a  sympa- 
thetic connection, — as,  for  instance,  otalgia,  hemicrania,  or  even 
sciatica,  from  an  exposed  tooth-pulp,  from  a  splinter  of  foreign  sub- 
stance, or  from  the  pressure  of  an  exostosis.  It  is  certainly  true 
that  there  is  a  class  of  persons  who  might  be  termed  neuralgic ; 
these  do  not  belong  strictly  to  what  is  called  the  nervous  tempera- 
ment, but  are  the  anaemic  and  prostrated.  A  plethoric  temperament 
disposes  to  inflammation,  but  plethora  is  not  inflammation  ;  it  is  only 
a  predisposition  ;  the  nervous  temperament  is  only  a  predisposition. 

*Dr.  Anstie,  whose  monograph  on  Neuralgia  has  attracted  much  attention, 
as  well  as  criticism  for  and  against,  advances  and  defends  the  position  that 
as  regards  both  the  seat  of  what  must  be  the  essential  part  of  the  morbid  pro- 
cess, and  the  general  nature  of  the  process  itself,  we  must  possess  very  definite 
information  indeed.  In  the  beginning  of  his  third  chapter  he  says,  "  I  ex- 
pect to  convince  most  readei-s  tluit  the  essential  seat  of  every  true  neuralgia 
is  the  posterior  root  of  the  spinal  nerve  in  which  the  pain  is  felt,  and  that  the 
essential  condition  of  the  tissue  of  that  nerve-root  is  atrophy,  which  is  usually 
non-inflammatory  in  origin.'"  (P.  110  J  There  can  be  no  doubt  that  such 
condition  is  to  be  met  with  as  an  explanation  of  peripheral  pain ;  but  such  a 
condition  is  merely  one  of  the  neuralgias. 


NEURALGIA.  711 

It  cannot  be  denied  that  cases  called  neuralgia,  and  treated  without 
ideas  of  a  definite  lesion,  do  very  frequently  get  well  ;  but  has  not 
the  indication  been  accidentally  met,  just  as  with  the  Dewee's  car- 
minative we  treat  the  restless  child  and  cure  it  without  definite  idea 
of  the  ailment,  having  in  a  single  medicine  the  requirement  of  various 
conditions  ?     I  think  this  is  so. 

If  neuralgia,  then,  is  simply  a  phenomenon, — simply  the  expres- 
sion of  an  immediate  or  distant  lesion, — the  preliminary  treatment 
must  lie  in  a  search  after  a  cause.  But  is  this  cause  always  evident  ? 
It  is  not,  at  least  to  our  present  acquirements :  nevertheless,  it 
exists,  and,  failing  to  discover  it,  we  are  compelled  to  desert  princi- 
ples and  experimentally  treat  with  the  hope  of  an  accidental  success. 

Are  there  predisposing  causes  of  pain-radiation  ?  Undoubtedly 
there  are,  and  these  may,  and  always  should,  receive  a  proper  degree 
of  attention,  as,  in  guarding  against  them,  it  might  be  that  the 
proper  lesion  would  not  in  itself  be  sufficient  to  inaugurate  or 
maintain  the  neuralgia.  Thus,  of  the  exciting  causes,  a  damp, 
cold  atmosphere  is  probably  one  of  the  most  potent.  Fatigue, 
over-excitement,  excess  in  drinking,  poor  diet,  the  too  free  use  of 
coffee  or  tea,  loss  of  sleep,  costiveness,  diarrhoea, — in  short,  anything 
which  interferes  with  the  easy  and  proper  performance  of  functional 
life. 

In  miasmatic  neighborhoods,  neuralgia  frequently  assumes  the 
periodic  type,  evidently  influenced  by  the  malaria.  And  it  is  with- 
out doubt  true  that  the  exhibition  of  quinine  will  and  does,  not  un- 
frequently,  cure  such  cases.  Whether  this  is  because  the  medicine 
controls  the  full  and  complete  cause  of  the  trouble,  or  only  removes 
an  exciting  cause,  in  the  absence  of  which  nature  gains  the  mastery, 
I  scarcely  know,  it  being  a  matter  of  certainty  that  it  is  by  no 
means  always  the  case  that  in  the  destruction  of  the  periodicity  the 
pain  is  removed. 

Syphilis  is  another  of  the  exciting  causes  of  neuralgia.  I  have 
known  a  patient  have  great  pain  from  diseased  teeth,  which  could 
be  held  completely  under  control,  although  not  cured,  by  iodide  of 
potassium.  The  pain  was  undoubtedly  from  the  teeth,  as  with  the 
subsequent  removal  of  these  organs  the  trouble  disappeared.    * 

To  epitomize  the  subject,  we  might  say  that  in  a  state  of  health 
the  nervous  system  represents  the  poised  balance :  it  is  neither 
excited  nor  depressed;  it  works  in  entire  harmony  with  its  require- 
ments. Apply  now  a  source  of  irritation,  and  this  harmony  or 
balance  is  destroyed.     According  as  the  amount  and  extent  of  irrita- 


712  ORAL   DISEASES  AND  SURGERY. 

tion,  so  are  the  amount  and  extent  of  derangement.  Life,  says  Bichat, 
rests  upon  the  tripod  of  innervation,  respiration,  circulation.  What- 
ever affects  one  of  these  legs  affects  the  whole  body.  To  appreciate 
the  phenomena  of  neuralgia  is,  then,  to  appreciate  the  phenomena 
of  irritation, — is  to  search  over  the  economy  until  whatever  lesion 
exists  is  exposed  and  comprehended. 

If  a  first  view  is  dii'ected  to  the  nervous  system  itself,  we  look 
for  a  lesion  in  the  part  which,  by  the  expression  of  pain,  seems  most 
markedly  implicated.  The  most  decided  cases  of  neuralgia  are, 
without  doubt,  odontalgic.  A  tooth  decays  until  the  cavity  contain- 
ing the  delicate  nerve  is  exposed ;  the  neuralgia  has  the  simple, 
single  signification  of  a  direct  irritation.  Exostosis  of  a  tooth-root 
presses  on  nerves  ramifying  in  the  alveolo-dental  membrane;  the 
signification  is  a  similar  one. 

Let  us  refer  to  a  neuralgia  occurring  in  the  stump  of  amputation. 
Is  the  cause  not  most  frequently  found  in  the  squeezing  and  pinching 
of  a  nerve  caught  in  the  cicatrix  ?  Is  it  not  the  same  history  where 
tumors  grow  about  and  press  upon  some  nerve-periphery?  But  I 
had  meant  rather  just  here  to  call  attention  to  derangement  in  nerve- 
substance  itself,  without  associated  or  influencing  lesion,  if  we  might 
be  able  to  find  such  derangements.  Might  I  instance  neuromatous 
expansion  as  found  in  stumps,  and  which  are,  evidently  enough, 
sources  of  pain  ?  Are  there  idiopathic  inflammations  of  nerve-sub- 
stance ?  or  do  nerves  in  themselves  degenerate  and  ulcerate?  We 
may  look  at  the  subject  from  a  still  wider  stand-point.  There  is  no 
earthly  doubt  that  a  pure  nervous  irritation  of  the  system  at  large 
may  exist.  There  is  certainly  an  individuality  existing  in  this 
system.  It  has  a  mode  of  action  of  its  own,  and  this  action,  as 
remarked  by  Dr.  Wood,  is  susceptible  of  exaltation,  depression,  or 
deprivation  in  itself,  and  from  the  influences  of  its  own  peculiar 
agents.  But  can  or  do  these  vicissitudes  express  themselves  ever, 
or  even  occasionally,  in  sharp  neuralgic  pains  ?  Connected  with  the 
digestive  function  we  have  often  nausea  and  vomiting;  with  the 
secretory,  disorder  of  the  liver  and  kidneys;  with  the  respiratory, 
hurried  and  otherwise  irregular  breathing;  with  the  circulatory,  a 
frequent  and  agitated,  though  seldom  full  or  energetic,  pulse.  "  As  the 
offices  of  the  brain,"  suggests  Prof  Wood,  "  are  various,  so  also  must 
be  the  signs  of  its  excessive  excitation.  Irritation  in  the  brain  obeys 
the  general  laws  of  that  morbid  affection.  If  moderate,  it  exalts  the 
healthy  functions  without  otherwise  altering  them  ;  if  stronger,  it 
more  or  less  degenerates  the  functions ;  in  great  excess,  it  entirely 


NEURALGIA.  713 

changes  or  abolishes  them.  Thus,  sensation  and  perception  may 
be  rendered  simply  more  acute,  or  may  be  deranged,  producing 
vertigo,  pain,  and  every  variety  of  disorder  in  vision,  hearing,  touch, 
etc.,  from  buzzing  in  the  ears,  unnatural  coloring  of  objects,  a  sense 
of  tingling,  formication,  etc.,  to  complete  hallucination.  The  intel- 
lectual faculties  and  the  emotions  may  be  excited  into  increased 
vigor,  or  may  be  completely  perverted,  as  in  delirium  and  insanity. 
The  general  overseeing  faculty  of  the  brain  may  be  simply  stimu- 
lated to  increased  vigilance,  to  a  more  ready  and  rapid  response  to 
all  the  intimations  of  its  dependent  functions ;  or  it  may  be  thrown 
into  excessive  disorder,  evinced  by  restlessness,  jactitation,  obstinate 
sleeplessness,  etc.  The  motor  faculty  may  merely  impart  increased 
activity  and  energy  to  the  muscles  under  the  influence  of  the  will; 
or  it  may  throw  off  more  or  less  completely  subordination  to  that 
principle,  and  give  rise  to  every  variety  of  spasm  and  convulsion. 
Finally,  all  the  functions  above  referred  to  may  be  overwhelmed  by 
an  excess  of  irritation,  and  more  or  less  completely  lost  in  stupor 
and  coma.  This  is  nerve-irritation,  from  causes  or  influences  which 
reside  in,  or  in  association  with,  the  system,  and  to  be  considered 
alone  in  connection  with  the  system." 

Reactions  of  vascular  perversion  on  the  nervous  system  are  to 
be  considered.  Coup-de-soleil  and  apoplexy  may  be  esteemed  the 
opposite  conditions  in  such  reactions.  How  frequently  have  all  the 
phenomena  of  partial  compression — headache,  giddiness,  buzzing  in 
the  ears,  disordered  vision,  tingling,  formication,  numbness,  drowsi- 
ness, mental  confusion,  spasms,  convulsions,  etc. — been  quickly  re- 
solved and  removed  by  the  accidental  rupture  of  a  nasal  vein  having 
communication  with  a  meningeal  sinus  1  And  how  happily,  when 
similar  conditions  have  come  on  from  long-continued  chlorosis,  has  a 
course  of  iron  relieved  them  1  Every  portion  of  the  encephalic  mass, 
every  portion  of  its  continuation  in  the  spinal  canal,  every  nerve- 
periphery,  requires  a  certain  amount  and  a  certain  character  of 
blood  to  keep  it  in  proper  poise  and  nutrition.  Too  much  blood,  and 
too  nutritious,  and  we  have  derangement  from  over-stimulation  ; 
too  little,  and  too  poor,  we  have  it  from  lack  of  pressure,  lack  of 
nutrition,  and,  in  many  cases,  from  effusions. 

Derangements  in  respiration  act  as  predisposing  causes  to  neu- 
ralgia. A  patient  who  labors  under  an  inability  to  aerate  his  blood, 
whatever  may  be  the  cause,  fails  to  relieve  that  fluid  of  certain 
poisonous  qualities,  which,  of  necessity,  sooner  or  later  must  disturb 
the  nervous  economy. 


714  ORAL  DISEASES  AND  SURG  ERF. 

Anything  and  everything,  in  short,  it  may  be  said,  which  acts  as 
a  depressant  in  the  vital  economy,  whether  by  over-stimulation  or 
by  under-nutrition,  is  to  be  thought  of,  and  considered,  in  neural 
derangements ;  overstud}',  sensual  excess,  indigestion,  hepatic  and 
nephritic  diseases,  repression  of  the  cutaneous  circulation,  the  de- 
pressing passions,  as  fear,  grief,  melancholy  ;  the  employment  of 
sedative  poisons,  as  opium,  tobacco,  chloroform  ;  living  in  an  atmos- 
phere impregnated  with  irrespirable  gases, — any  of  these  may- 
assist  some  otherwise  incapable  lesion  in  determining  an  attack  of 
neuralgia. 

The  most  extreme  case  of  nervous  mania  that  has  ever  come 
under  my  own  observation,  accompanied  with  general  hyperaes- 
thesia  and  local  neuralgia,  was  in  the  person  of  a  carter,  addicted  to 
smoking.  For  three  days  this  man  was  uncontrollable  by  any  but 
physical  restraint;  at  the  end  of  which  period,  having  secured  a 
short  interval  of  sleep  and  quiet,  I  placed  between  his  lips  a  pipe  of 
the  strongest  tobacco.  I  finally  cured  the  patient,  making  the  sec- 
tion of  a  nerve,  and  treating  him  with  tobacco  and  sedatives,  just  as 
one  treats  delirium  tremens  with  w4iisky  and  sedatives.  In  this  case 
I  am  entirely  satisfied  that  the  local  neuralgia  was  goaded  to  its 
intensity  by  the  perverted  condition  of  the  general  nervous  system. 
Several  cases  of  similar  import  I  can  recall,  associated  with  the 
improper  use  of  opium,  and  with  the  abuse  of  the  sexual  instincts. 

In  the  cases  of  persons  long  habituated  to  the  use  of  opiates  as  a 
relief  in  neuralgic  pain,  operations  which  have  considered  and  which 
have  truly  relieved  the  system  of  the  lesion  of  offense  are  not  apt 
to  be  followed  by  the  immediate  relief  anticipated.  Here  is  a  point 
in  which  the  most  practical  experience  agrees  with  certain  deduc- 
tions of  Dr.  Anstie,  that  "  pain  involves  a  lowering  of  function  ;" 
while,  on  the  other  hand,  it  would  not  seem  so  reasonable  to  admit 
that  it  is  "  not  a  hyperaesthesia."  Pain  is  of  both  conditions,  and  is 
to  have  such  appreciation  if  it  is  to  have  cure. 

The  first  of  the  propositions  finds  demonstration  plain  enough  in 
the  exhibitions  of  the  inebriate,  who  manifests  the  first  symptoms  of 
delirium  only  on  the  deprivation  of  the  wonted  stimulus,  his  aberra- 
tion having  the  meaning  of  exhaustion  consequent  on  over-stimula- 
tion, as  shown  in  what  might  be  termed  the  synthetical  proof  of  the 
primary  demand  for  stimulation. 

From  his  own  practice  the  author  might  cite  many  interesting 
cases  illustrative  of  the  difficulty  of  affording  ease  to  a  patient  ad- 
dicted to,  and  long  dependent  on,  opiates,  even  where  the  original 


NEURALGIA.  715 

disease  undoubtedly  had  been  cured, — as,  for  example,  in  such  in- 
stances as  the  removal  of  cicatrices  or  of  foreign  bodies  ;  these  cases, 
however,  are  not  at  all  in  proof  of  the  neuralgia  being  a  disease  in 
itself,  but  rather  the  reverse ;  the  pain  is  the  expression  of  weak- 
ness, of  exiiaustion.  No  lesion  remains  to  be  considered.  Cure  is 
to  be  found  in  getting  back  the  lost  equipoise.  Exactly  what  this 
lost  equilibrium  may  be  called  is  entirely  immaterial.  Let  it  be 
named  vaso-motor  paralysis,  as  designated  by  Dr.  Anstie,  and  let  it 
be  said  that  the  paralysis  is  a  "  direct  extension  of  the  original  mor- 
bid process  from  the  sensory  root  to  the  motor,  affecting  the  original 
fibres  in  the  latter,  which  are  destined  to  control  the  calibre  of  the 
ocular  and  facial  vessels."  Granting  the  premise  of  neuralgia  being 
an  expression  of  the  presence  of  an  irritant,  or  accepting  the  hypothesis 
of  Anstie  as  to  its  being  a  condition  of  diminished  vitality,  it  must 
certainly  be  felt  that  the  hypodermic  injection  of  morphia, — of  ob- 
tunding  agents, — so  continuously  practiced  and  recommended,  has  in 
it  only  the  virtue  of  covering  a  wound  temporarily  from  sight  and 
calling  it  well :  indeed,  it  is  much  worse  than  this,  it  is  exhausting 
more  completely  that  which  is  already  exhausted  ;  it  is  medicating 
an  effect  and  taking  no  heed  of  that  which  is  the  cause  of  the  effect. 

The  meaning,  however,  is  not  designed  to  be  conveyed  that  the 
opiates  are  not  justifiably  to  be  used  in  neuralgic  conditions;  pain 
in  itself  is  a  cause  of  exhaustion,  and  it  may  prove  the  lesser  of  two 
evils  to  moderate  or  annul  pain  ;  but  opiates  are  to  be  employed  as 
adjuncts.  When  we  find  ourselves  forced  to  rely  upon  them,  the 
confession  is  extorted  that  we  know  solidly  nothing  at  all  about  the 
case  we  are  so  treating. 

In  a  letter  to  the  London  Times,  republished  in  the  Medical 
Times  and  Gazette,  Sir  Benjamin  Brodie  expresses  his  general  dis- 
approbation of  the  habitual  use  of  tobacco,  and  makes  the  following 
observations  on  its  deleterious  effects: 

"The  effects  of  this  habit  are  indeed  various,  the  difference  de- 
pending on  difference  of  constitution  and  difference  in  the  mode  of 
life  otherwise.  But,  from  the  best  observations  which  I  have  been 
able  to  make  on  the  subject,  I  am  led  to  believe  that  there  are  very 
few  who  do  not  suffer  harm  from  it,  to  a  greater  or  less  extent.  The 
earliest  symptoms  are  manifested  in  the  derangement  of  the  nervous 
system.  A  large  proportion  of  habitual  smokers  are  rendered  lazy 
and  listless,  indisposed  to  bodily,  and  incapable  of  much  mental,  ex- 
ertion. Others  suffer  from  depression  of  the  spirits,  amounting  to 
hypochondriasis,  which  smoking  relieves  for  a  time,  though  it  ag- 


716  ORAL  DISEASES  AND   SURGERY. 

gravates  the  evil  afterward.  Occasionally  there  is  a  general  nervous 
excitability,  which,  though  very  much  less  in  degree,  partakes  of  the 
nature  of  the  delirium  tremens  of  drunkards.  I  have  known  many  in- 
dividuals to  suffer  from  severe  nervous  pains,  sometimes  in  one,  some- 
times in  another  part  of  the  body.  Almost  the  worst  case  of  neuralgia 
that  ever  came  under  my  observation,  was  that  of  a  gentleman  who 
consulted  the  late  Dr.  Bright  and  myself.  The  pains  were  universal, 
and  never  absent;  but  during  the  night  they  were  especially  intense, 
so  as  almost  wholly  to  prevent  sleep.  Neither  the  patient  himself 
nor  his  medical  attendant  had  any  doubts  that  the  disease  was  to  be 
attributed  to  his  former  habit  of  smoking,  on  the  discontinuance  of 
which  he  slowly  and  gradually  recovered.  An  eminent  surgeon, 
who  has  a  great  experience  in  ophthalmic  diseases,  believes  that,  in 
some  instances,  he  has  been  able  to  trace  blindness  from  amaurosis 
to  excess  in  tobacco-smoking  ;  the  connection  of  the  two  being 
pretty  well  established  in  one  case  by  the  fact  that,  on  the  practice 
being  left  off,  the  sight  of  the  patient  was  gradually  restored.  It 
would  be  easy  for  me  to  refer  to  other  symptoms  indicating  deficient 
power  of  the  nervous  system  to  which  smokers  are  liable ;  but  it  is 
unnecessary  for  me  to  do  so;  and,  indeed,  there  are  some  which  I 
would  rather  leave  them  to  imagine  for  themselves  than  undertake 
the  description  of  them  myself  in  writing. 

"But  the  ill  effects  of  tobacco  are  not  confined  to  the  nervous 
system.  In  many  instances  there  is  a  loss  of  the  healthy  appetite 
for  food,  the  imperfect  state  of  the  digestion  being  soon  rendered 
manifest  by  the  loss  of  flesh  and  the  sallow  countenance.  It  is  dif- 
ficult to  say  what  other  diseases  may  not  follow  the  imperfect  as- 
similation of  food  continued  during  a  long  period  of  time.  So  many 
causes  are  in  operation  in  the  human  body  which  may  tend  in  a 
greater  or  less  degree  to  the  production  of  organic  changes  in  it,  that 
it  is  only  in  some  instances  we  can  venture  to  pronounce  as  to  the 
precise  manner  in  which  a  disease  that  proves  mortal  has  origi- 
nated. From  cases,  however,  which  have  fallen  undei»  my  own  ob- 
servation, and  from  a  consideration  of  all  the  circumstances,  I  cannot 
entertain  a  doubt  that,  if  we  could  obtain  accurate  statistics  on  the 
subject,  we  should  find  that  the  value  of  life  in  inveterate  smokers  is 
considerably  below  the  average.  Nor  is  this  opinion  in  any  degree 
contradicted  by  the  fact  that  there  are  individuals  who  in  spite  of 
the  inhalation  of  tobacco-smoke  live  to  be  old,  and  without  any  ma- 
terial derangement  of  the  health;  analogous  exceptions  to  the  gen- 


1 


NEURALGIA.  717 

eral  rule  being  met  with  in  the  case  of  those  who  have  indulged  too 
freely  in  the  use  of  spirituous  and  fermented  liquors." 

With  such  general  considerations  of  the  matter,  it  may  prove 
most  advantageous  to  pass  to  illustrations  in  the  recital  of  individual 
cases.  With  the  data  afforded  by  such  a  review,  we  may  with  more 
satisfactory  premises  appreciate  the  principles  of  cure. 

Case  I. — Mrs.  B.,  the  wife  of  an  undertaker,  suffered  for  a  long 
time  from  periodic  attacks  of  pain  about  the  face  and  head.  This 
person,  exceedingly  quiet  and  retiring,  spent  most  of  her  life  in 
sunless  rooms,  surrounded  by  the  melancholy  paraphernalia  pertain- 
ing to  the  business  of  her  husband.  She  was  anaemic,  and  of  poor 
general  health  and  spirits.  Although  this  patient  had  certain  bad 
teeth,  yet  the  pain  had  never  seemed  associated  with  them ;  indeed, 
so  insensible  were  these  organs  to  ordinary  agents  of  irritation,  that 
a  diagnosis  was  founded  alone  on  her  general  condition  and  sur- 
roundings, and  remedies  applied  entirely  in  such  direction.  Tonics 
were  administered,  window-shutters  were  unbowed,  exercise  and 
amusement,  conjoined  with  generous  living,  were  advised ;  even 
with  this  entire  change  the  patient  failed  to  improve,  but,  on  the 
contrary,  grew  worse.  The  diagnosis  thus  discovered  to  be  at  fault, 
the  teeth  were  extracted;  still  the  condition  persisted,  and  the  pain 
increased.  She  was  now  treated  for  over  a  year,  the  pharmacopoeia 
being  exhausted  in  her  case.  Called  in  consultation,  and  acting  on 
the  belief  of  the  existence  of  a  special  lesion  in  all  such  cases,  I 
determined,  with  the  concurrence  of  the  gentleman  in  attendance  on 
the  case,  to  make  a  most  careful  exploration  of  her  whole  system. 
At  this  period  the  pain  had  assumed  and  continued  the  impression 
of  an  iron  clamp  over  the  head,  terminating  beneath,  and  which 
clamp  seemed  daily  contracting  itself.  The  terror  and  pain  of  this 
impression  had  become  so  great  as  to  convert  the  patient  almost  into 
a  lunatic.  I  found,  on  inquiry,  that  her  internal  organs  had  been 
most  carefully  examined,  and  inferred  not  to  be  in  fault.  My  own 
investigations,  therefore,  were  commenced  externally.  First,  was 
there  any  remaining  tooth  or  teeth  implicated  ?  1  examined  for 
caries,  for  pulpitis,  for  nodules,  for  necrosis,  for  supernumerai-y  teeth, 
for  exposed  cementum,  but  fully  assured  myself  these  organs  were 
in  no  wise  involved.  I  examined  the  spinal  cord,  and,  through  its 
expressions,  the  encephalic  mass;  organically,  the  trouble  could  not 
be  found  reflex  from  these  points.  I  examined  every  articulation, 
the  line  of  every  artery,  vein,  and  nerve,  so  far  as  I  might  follow 
them.     I  passed  in  review  every  observation  and  fact  which  might 


718  ORAL  DISEASES  AND  SURGERY. 

enlighten  me,  but  without  success,  so  far  as  any  discovery  of  an 
exciting .  cause  was  concerned.  Finally,  I  returned  to  the  oral 
cavity.  The  teeth  which  had  been  extracted  the  year  before  were 
the  molars  and  premolars  of  the  left  superior  jaw.  Might  there  not 
possibly  have  been  just  the  smallest  particle  of  one  of  these  teeth 
left  in  its  socket  ?  I  was  making  pressure  in  the  canine  fossa,  when 
the  patient  made  slight  complaint;  it  was  the  only  point  which 
yielded  difference  in  sensation.  Now,  what  was  this  sensation,  and 
what  did  it  mean  ?  It  was  not  pain  of  which  the  patient  com- 
plained, not  discomfort ;  it  was  simply  diff"ereuce  of  sensation.  But 
it  was  the  only  point  which  had  yielded  expression;  it  was  there- 
fore diff"erentially  just  to  infer  that  here  existed  something, — the 
lesion,  perhaps,  of  which  we  were  in  search.  Acting  on  this  hint, 
I  obtained  the  consent  of  my  colleague  to  make  an  exploratory  tre- 
phine of  the  antrum,  and,  on  performing  the  operation,  discovered 
that  branches  of  the  intraorbital  nerve  running  across  the  cavity 
had  enlarged  to  the  size  of  knitting-needles.  These  enlarged  nerves, 
of  which  there  were  two,  I  cut  away.  The  patient  was  immediately 
relieved,  and,  although  three  years  have  passed,  she  has  bad  no 
recurrence  of  her  neuralgia. 

Case  II. — In  October,  1868,  I  treated  and  dismissed  a  patient,  a 
young  lady,  who  shortened  a  summer  and  fall  campaign  to  come  to 
Philadelphia  for  advice  concerning  neuralgia  of  the  face,  and  of  the 
ear  and  scalp.  She  described  iier  agony  as  being  sometimes  so  great 
that  only  from  chloroform  could  she  get  even  a  temporary  relief; 
had  been  taking  tonics  and  opiates  throughout  the  summer;  had  no 
pain  in  any  of  her  teeth,  although  on  the  upper  jaw  was  a  pulpless 
molar.  Examining  her  mouth,  my  attention  was  attracted  to  a 
peculiar  overriding  of  the  second  bicuspid  tooth  of  the  lower  jaw  by 
the  first  molar;  the  employment  of  a  delicate  curved  probe  revealed 
caries  of  the  first  of  these  teeth  exposing  the  pulp ;  the  tooth  was 
extracted,  and  the  distant  and  apparently  dissociated  neuralgia  in- 
stantly disappeared. 

A  tendency  to  nervous  irritability  which  exists  in  this  patient 
may  very  well  be  re-aroused  by  the  presence  of  the  upper  dead 
molar ;  if  this  should  prove  to  be  the  case,  she  is  advised  to  have  it 
extracted. 

Case  III. — "  Softenivg  of  Inferior  Dental  Nerve  ;  Exostosis  of 
Infra-orbital  Canal ;  Trephining;  Cure.  Professor  Greene's  Clinic 
in  the  Medical  School  of  Maine. — Mrs.  W.,  aged  fifty-four.  About  three 
years  ago,  patient  began  to  suff"er  from  pain  at  the  angle  of  the  lower 


NEURALGIA.  719 

jaw  on  the  right  side.  This  was  paroxysmal  in  its  character ;  but 
the  attacks  were  so  frequent  and  severe  as  to  unfit  her  for  usefulness 
or  enjoyment.  Her  sufferings  hud  been  much  increased  during  the 
past  year,  and  the  pain  now  affected  the  whole  side  of  the  face, 
being  quite  severe  in  the  infra-  and  siipra-ov\)\\.?i\  regions.  There 
was  no  tenderness  or  swelling  ;  no  apparent  derangement  of  the 
general  health  that  was  not  referable  to  the  local  suffering.  She 
had  undergone  most  thorough  medical  treatment,  both  general  and 
local,  in  the  hands  of  good  physicians,  with  no  avail.  Hypodermic 
injections  of  morphine  and  atropia  had  failed  to  afford  any  perma- 
nent relief.  Professor  Greene  said,  that  from  the  fact  that  there 
was  no  failure  of  the  general  health  previous  to  the  local  trouble, 
and  none  now  except  the  debility,  fairly  attributable  to  the  long- 
continued  pain,  and  also  the  fact  that  the  various  plans  of  treatment, 
whether  alterative  or  tonic,  combined  with  the  most  powerful  ano- 
dynes, had  failed,  it  was  probable  that  the  disease  was  local  in  its 
character.  Whether  the  inferior  dental  nerve  alone  was  involved, 
or  whether  the  main  trunk  or  the  fifth  pair  was  diseased,  was 
doubtful ;  but,  as  the  pain  was  so  completely  localized  at  the  angle 
of  the  jaw  at  the  outset,  and  so  remained  for  many  months,  the 
probabilities  were  that  the  pain  along  the  other  branches  was  reflex. 
At  any  rate,  it  was  one  of  those  cases  where  we  are  justified  in  tre- 
phining the  jaw  and  exposing  the  nerve.  We  might  find  the  nerve 
inflamed  or  softened,  or  pressed  upon  by  a  little  bony  tumor  pro- 
jecting within  the  dental  canal.  Oftentimes  these  cases  were  asso- 
ciated with  and  dependent  upon  ostitis  or  caries,  but  here  there  was 
no  evidence  of  diseased  bone.  The  two  last  molars  had  been  ex- 
tracted years  before,  but  the  parts  seemed  healthy.  Dr.  G.  had 
operated  in  one  case  where  tlie  nerve  and  the  surrounding  bone 
appeared  perfectly  healthy,  but  perfect  relief  followed  division  of 
the  nerve. 

"  Ether  was  given,  and  a  curved  incision,  with  its  convexity  look- 
ing downward  and  backward,  made  over  the  angle  of  the  jaw,  the 
bone  carefully  exposed,  and  with  a  small  trephine  a  button  of  bone 
removed,  exposing  the  dental  canal.  The  nerve  was  found  so  much 
softened  as  to  lacerate  readily  when  the  attempt  was  made  to  raise 
it  from  its  bed.  The  exposed  portion  was  all  removed,  the  wound 
closed  with  silver  sutures,  and  a  wet  compress  applied.  The  relief 
from  pain  at  this  point  was  immediate  and  complete.  The  lady  slept 
well  without  anodynes,  and  in  a  week  returned  home,  well,  with  the 
exception  of  some  pain  still  existing  in  the  infra-orbital  region. 


720  OBAL  DISEASES  AND  SURGERY. 

"  At  tbe  end  of  six  weeks  she  returned,  complaining  of  a  great 
increase  of  suflFeriug.  The  pain  was  well  localized,  and  entirely 
neuralgic  in  its  character.  Ether  was  again  administered,  and  by  a 
curved  incision  the  nerve  was  exposed  at  its  exit  from  the  infra- 
orbital foramen.  It  appeared  to  be  perfectly  healthy ;  but,  upon 
cutting  away  the  walls  of  the  canal  for  half  an  inch,  a  little  sharp 
exostosis  was  seen  upon  the  right  side,  pressing  upon  and  flattening 
the  nerve.  This  was  removed,  the  wound  closed,  and  simple  dress- 
ings applied.     The  relief  was  immediate  and  complete." 

Case  IY. — Neuralgia  of  Neck  and  Arm  from,  Carious  Molar. 
— Dr.  Hyde  Salter,  well  known  in  connection  with  clinical  practice, 
had  suffered  much  from  attacks  of  inflammation  in  the  left  lower 
anterior  molar,  which  was  extensively  excavated  by  caries.  At  the 
age  of  seventeen  these  acute  symptoms  had  ceased  for  two  or  three 
years,  leaving  nothing  but  a  grumbling  uneasiness  in  it.  At  this 
time  neuralgic  pains  began  to  extend  from  the  tooth  down  into  the 
neck  and  left  side,  and  thence  over  the  collar-bone  down  the  left 
arm, — these  pains  enduring  several  days  and  then  remitting.  There 
was  no  actual  pain  in  the  tooth  itself,  nor  any  tenderness  in  it,  nor 
in  the  adjacent  gum,  nor  any  appearance  of  inflammation.  The 
situation  of  the  pain  in  the  neck  and  clavicular  and  supramaxillary 
regions  was  exactly  that  of  the  descending  cutaneous  branches  of 
the  cervical  plexus,  and  the  part  of  the  arm  where  the  aching  was 
the  most  intense  and  intolerable  was  at  the  insertion  of  the  deltoid. 
These  symptoms  disappeared  with  the  extraction  of  the  offending 
tooth,  and  have  never  since  returned. 

Case  Y. — Intense  Neuralgia  of  the  Eyeball  and  Face ;  Altera- 
tion of  the  Color  of  the  Iris;  Carious  Teeth. — Mrs.  C,  aged 
thirty,  had  suffered  for  ten  years  from  severe  neuralgia,  affecting 
the  left  eyeball  and  left  side  of  the  head  and  face,  the  iris  of  the 
affected  eye  having  changed  from  a  deep  and  bright  hazel  to  a  dull 
gray.  The  left  lower  dens  sapientiae  and  the  first  upper  bicuspid 
being  found  badly  carious,  these  were  extracted,  and  the  operation 
was  attended  by  a  terrible  paroxysm  of  neuralgia  ;  but  after  this  had 
subsided  the  patient  experienced  relief  for  about  three  months, 
when,  the  old  pain  returning,  the  second  upper  bicuspid  was  found 
to  be  carious  and  intensely  tender,  and  upon  its  removal  a  consider- 
able exostosis  was  found  on  the  root.  The  pain  vanished  with  the 
tooth. — (Guy^s  Hospital  Reports.) 

Case  YI. — Neuralgia  of  Loxcer  Jaw;  Necrosis. — M.  C,  a 
laborer,  applied   for   treatment,    complaining   of  unbearable   pain 


NEURALGIA.  721 

situated  about  the  roots  of  the  inferior  central  incisor  teeth.  The 
most  careful  examination  revealed  no  explanation,  and  the  patient 
was  dismissed  for  the  day  with  an  opiate  prescription.  A  second 
examination,  and  many  succeeding  ones,  failed  to  yield  a  diagnosis, 
opiates  being  continued  during  the  period.  At  the  end  of  some 
three  weeks  an  inflammation  supervened,  resisted  all  treatment, 
and  finally  terminated  in  a  necrosis,  which  cast  off  the  two  teeth 
with  their  alveoli;  the  exfoliation  completed,  the  neuralgia  disap- 
peared. 

Case  VII. — Dr.  Benjamin  Rush  relates  a  case  of  neuralgia  in  the 
nates,  which,  resisting  other  means  of  treatment,  finally  yielded  to 
the  extraction  of  a  tooth. 

Case  VIII. — Megrim. — A  protege  of  the  Princess  of  Conde  was 
bled  in  the  arm  and  foot  twenty  times  for  megrim  of  five  years' 
standing.  It  at  last  being  thought  advisable  to  open  the  jugular 
vein,  the  princess  applied  to  M.  Petot  to  perform  the  operation. 
But  this  surgeon,  not  seeing  the  necessity  for  so  frequent  depletion, 
begged  to  examine  the  mouth,  and  found  in  the  lower  jaw,  in  which 
the  patient  had  for  a  long  time  had  pain  and  numbness,  eighteen, 
instead  of  sixteen,  teeth,  resulting  in  a  very  crowded  denture.  By 
extracting  the  second  molar  on  either  side,  he  gave  complete  and 
permanent  relief  in  twenty-four  hours. 

Case  IX. — Neuralgia  Faciei  and  Odontalgia  from  3Ienstrual 
Irregularities. — A  lady  of  rank  (Rayer),  long  suffering  from  amen- 
orrhoea,  was  subject  to  frequent  epistaxis,  pain  in  the  side,  and 
swelling  of  the  abdomen  and  feet.  These  symptoms  were  overcome, 
and  for  a  year  she  enjoyed  good  health ;  but  la.st  summer,  in  conse- 
quence of  mental  distress,  a  severe  neuralgia  came  on,  which  was 
cured  for  a  time,  but  soon  returned  with  the  following  curious 
symptoms:  every  evening  the  pains  recurred,  preceded  by  the  dis- 
charge from  between  the  upper  canine  and  bicuspis  of  the  left  side 
of  a  matter  which  was  at  first  thick,  viscid,  and  bloody,  but  after- 
ward clear  and  so  profuse  as  to  fill  a  small  vessel.  The  pains  con- 
tinued the  whole  night.  No  remedies  gave  any  relief  but  opiates, 
which  suppressed  both  the  pain  and  discharge  and  gave  sleep. 

Case  X. — A  nun  (Wepser),  aged  forty,  was  seized,  atone  of  her 
menstrual  periods,  with  pain  in  the  head,  eyes,  and  teeth.  A  tooth 
on  the  left  side  was  extracted,  but  without  relief;  the  pain  passed 
to  the  right  side,  and  for  five  weeks,  with  occasional  intervals  of 
from  half  a  day  to  two  days,  caused  much  suffering,  first  on  one 
side  of  the  head,  then  on  the  other,  the  principal  seat  of  the  pain 

46 


722  OBAL  DISEASES  AND   SURGERY. 

being  a  space  two  or  three  fingers  broad  on  the  side  of  the  head. 
When  the  attacks  were  violent  they  were  preceded  by  a  strongly- 
marked  chill,  the  throbbing  of  the  temporal  artery  was  very  per- 
ceptible, the  eye  injected,  and  when  the  paroxysms  were  at  their 
height  flushings  were  experienced.  In  the  treatment  of  this  case, 
as  tlie  teeth  were  discovered  to  be  not  at  all  in  fault,  the  surgeon 
opened  an  issue  in  each  arm  and  a  third  on  the  neck,  all  three  of 
which  were  made  to  discharge  freely.  Attention  was  also  paid  to 
the  nervous  system,  with  a  view  to  give  it  tone  and  strength.  Not 
much  regard  was  paid  to  the  amenorrhoea,  because  at  such  age  the 
menses  are  usually  very  scant. 

In  both  the  above  cases  the  practitioners  failed  of  a  successful 
treatment,  and  evidently  for  the  reason  that,  in  each  case,  treatment 
was  misdirected.  A  reflected  or  radiated  irritability  of  the  uterus 
was  without  doubt  the  lesion, — an  ulcer  or  other  local  lesion  being 
the  offense. 

Case  XI. — One  of  the  most  impressive  cases  of  neuralgia  ever 
treated  b}^  the  author  has  the  following  history.  A  Mr.  B.,  serving 
in  the  war  of  the  rebellion,  received,  as  near  as  memory  serves  to 
recall  the  case,  three  gunshot  wounds, — one  in  which  a  small  minie- 
ball  passed  through  the  tarsal  bones,  a  second  in  the  arm,  a  third 
perhaps  in  the  chest;  the  exact  locations  of  the  two  latter  are  not 
distinctly  recalled,  as  they  did  not  associate  with  the  case.  After 
dismissal  from  the  service,  and  after,  upon  his  return  home,  being 
engaged  for  a  long  period  in  the  occupation  of  a  carter,  the  patient 
commenced  to  experience  pain  in  the  knee-joint  and  down  the  back 
of  the  leg,  this  pain  during  a  period  of  months  increasing  to  such 
extent  in  severity  as  to  require  a  constant  watch  being  kept  to  pre- 
vent suicide.  The  author  feels  justified  in  asserting  that  seldom  is  wit- 
nessed greater  expression  of  agony  in  a  human  being  than  was  the 
almost  constant  condition  of  this  man.  Spending  two  months  in 
the  observation  and  clinical  study  of  this  case,  the  conclusion  eventu- 
ally forced  itself  upon  the  mind-  that  associated  with  the  track 
of  the  ball  through  the  foot  existed  some  lesion  of  the  anterior 
tibial  nerve.  Not  that  at  this  point  there  was  pain,  tenderness,  or 
indeed  expression  of  any  kind,  but  a  diagnosis  by  exclusion  seemed 
to  centre  the  trouble  here :  the  author  mentions  particularly  the 
absence  of  all  signs,  because  he  could  find  no  one  to  second  his 
conclusions  or  to  indorse  a  proposition  to  make  section  of  the  nerve 
above  the  ankle.  The  nerve,  however,  was  exposed  and  a  section 
of  an  inch  removed.     From  the  moment  of  the  operation  the  patient 


NEURALGIA.  728 

was  entirely  free  from  his  neuralgia,  although  tenderness  about  the 
knee  upon  pressure  continued  for  some  little  time,  while  the  super- 
ficial portions  overlying  both  malleoli  sloughed  and  remained  in  an 
ulcerating  condition  over  three  months.* 

Affections  of  the  Nervous  System  dependent  on  Diseases  of 
the  Permanent  Teeth. — Mr.  Salter  contributes  to  Guy's  Hospital 
Reports  a  most  interesting  paper  under  the  foregoing  title,  which 
contains  much  information  of  direct  and  practical  value.  "Disorders 
of  this  kind,"  says  Mr.  Salter,  "  are  divided  into  those  which  are 
reflex,  secondary,  and  remote ;  and  those  which  are  direct,  imme- 
diate, and  from  contiguity.  In  the  former  category  would  rank 
epilepsy,  neuralgia,  paralysis ;  in  the  latter,  local  pain,  facial  palsy, 
some  forms  of  amaurosis,  etc.  In  other  instances,  such  as  those  in 
which  exalted  sensibility  of  the  tegumentary  nerves  of  the  face,  or 
erratic  pains  through  the  maxillary  nerves,  are  associated  with 
toothache,  it  might  be  difficult  to  say  whether  the  phenomena  are 
mostly  reflex  or  direct ;  they  probably  comprise  both  conditions. 
.  .  .  The  posterior  lower  molars  are  but  little  removed  from  the 
tonsils  and  Eustachian  tube,  from  the  parotid  region,  and  from  the 
external  auditory  passage.  The  fangs  of  the  upper  back  teeth  are 
close  to  the  orbit  and  its  all-important  contents  ;  and  more  posteriorly 
they  approach  the  spheno-maxillary  fossa  and  fissure.  •  Thus  it  is 
easy  to  account  for  the  nervous  complications  which  are  directly 
entailed  by  the  spread  of  inflammation  from  the  periosteum  of  dis- 
eased teeth. 

"By  far  the  commonest  reflex  nervous  disturbances  to  w^hich 
dental  irritation  gives  rise  are  neuralgic  pains  of  the  head ;  and  this 
is  especially  the  case  where  the  upper  teeth  are  implicated.     In  the 

*  Nutritive  changes  in  connective  tissue  consequent  on  nerve-wounds, 
founded  on  an  observation  of  one  hundred  and  sixty  cases,  are  referred  to  by 
Dr.  S.  Weir  Mitchell  in  his  valuable  contribution  to  the  study  of  nerve-lesions, 
"Injuries  of  Nerves."  "In  looking  over  my  notes,"  says  this  writer,  "I 
find  that  oedema  was  apt  to  come  on  suddenly  ;  sometimes  the  swelling  came 
and  went  without  obvious  cause,  and  sometimes  it  was  very  persistent  and 
accompanied  with  congestion  of  the  skin.  In  generalized  atrophic  condition 
of  a  limb,  the  connective  tissue  shared  the  loss  which  fell  upon  the  other  tissues, 
seeming  to  disappear  quite  as  rapidly  as  they.  It  is,  however,  indicative  of 
the  difficulties  which  surround  these  cases,  that  in  a  single  instance  I  have 
seen  a  nerve-wound  giving  rise  to  an  hj'pertrophic  state  of  the  connective 
tissues.  The  case  is  so  unusual  that  I  have  been  unable  to  match  it  either 
from  my  own  material  or  from  the  records  of  others.  Such  a  condition  of 
Sclerosis  of  the  areolar  tissues  is,  however,  a  rare  accident  of  spinal  myelitis." 


724  ORAL  DISEASES  AND  SURGERY. 

supra-  and  infraorbital  nerves,  the  globe  of  the  eye,  the  temples,  and 
particularly  a  spot  near  the  vertex,  a  little  on  one  side  (the  side  of 
the  affected  tooth),  in  all  these  regions  '  dental  neuralgia'  is  really 
very  common;  and  I  have  observed,  not  unfrequently,  that,  where 
the  pain  has  continued  long,  the  integument  has  become  hot,  and 
tender,  and  red.  .  .  . 

"  The  several  branches  of  the  trigeminus  appear  to  be  the  most 
susceptible  of  reflex  affection  caused  by  the  dental  irritation  of  one 
of  them ',  but  next  to  the  different  elements  of  the  fifth  nerve,  the 
branches  of  the  cervical  and  brachial  plexuses  are  most  commonly 
involved.  Thus,  pains  in  the  neck,  shoulder,  acromion  process,  in- 
sertion of  the  deltoid,  or  bend  of  the  elbow,  are  by  no  means  un- 
common, and  with  them  occasionally  a  loss  of  motor  power,  a  weary 
sense  of  fatigue  in  the  flexor  muscles,  and  an  inability  to  grasp 
firmly  with  the  hand.  It  would  really  seem  that  there  is  occasion- 
allv,  and  in  some  individuals,  a  special  and  exceptional  communica- 
tion between  the  fifth  nerve  and  those  of  the  arm.  Dr.  Anstie  has 
seen  two  instances  in  which  wounds  of  branches  of  the  ulnar  nerve 
have  caused  reflex  neuralgia  of  the  fifth  nerve.  And  he  remarks 
upon  this  circumstance,  '  That  the  mental  perception  of  the  patient 
should,  in  each  of  these  cases,  refer  the  pain,  not  to  any  point  in 
the  course  of  the  injured  nerve,  but  to  the  branches  of  the  trigeminal, 
affords,  in  my  opinion,  a  strong  suggestion  that  that  portion  of  the 
central  nervous  system  with  which  the  trigeminus  is  directly  con- 
nected, presents  some  congenital  or  acquired  peculiarity  of  organi- 
zation.' This  idea  is  fully  borne  out  by  what  one  occasionally, 
but  only  occasionally  and  exceptionally,  sees  in  the  occurrence  of 
brachial  neuralgia  and  paralysis  caused  by  dental  irritation  of  the 
branches  of  the  fifth  nerve. 

"  Reflex  nervous  irritation,  dependent  upon  dental  disease,  is 
most  uncertain  and  capricious  in  its  manifestations.  One  person 
will  suffer  much  from  a  comparatively  slight  cause,  while  in  others 
the  same  condition  more  severely  developed  will  produce  no  such 
result.  There  is,  unquestionably,  in  some  persons  a  neuralgic  diath- 
esis ;  and  it  is  not  improbable  also  that,  in  some  individuals,  there 
may  be  a  congenital  or  induced  peculiarity  in  the  centric  or,  perhaps, 
collateral  relations  of  certain  nerves,  by  which  the  exalted  polarity 
of  one  may  be  passed  on  and  so  reflected  upon  another  with  ab- 
normal facility.  In  persons  obnoxious  to  these  forms  of  neuralgia 
from  dental  irritation,  nothing  is  so  liable  to  produce  an  attack  as 
exhaustion  or  depressed  nutrition  ;  and  patients  will  often  tell  you 


NEURALGIA.  725 

that  the  attacks  only  come  on  when  they  are  very  tired,  or  have 
gone  long  without  food. 

"Pain  is  only  one  of  the  phenomena  of  reflex  dental  nerve  irrita- 
tion. It  may  induce  muscular  spasm,  muscular-  parahjsis,  paral- 
ysis of  some  of  the  nerves  of  special  sense,  perverted  nutrition. 

"As  regards  the  teeth  themselves  which  excite  this  exalted  ner- 
vous irritability,  nearly  all  their  diseases  appear  capable  of  causing 
this  condition.     Thus  : 

"  Caries,  with  or  without  exposure  of  the  pulp  ;  exostosis  ;  hy- 
pertrophy of  the  crusta  petrosa  ;  nodular  developments  of  dentine 
in  the  pulp  cavity  ;  periostitis,  plastic  or  superlative ;  impaction  of 
permanent  teeth  in  the  maxillary  bones  ;  crowding  of  teeth  from 
insufficient  room. 

"  Each  and  all  of  the  above-enumerated  abnormities  of  teeth  have 
caused  manifestations  of  reflex  nervous  irritation,  though,  as  I  have 
remarked,  they  may  exist  in  the  severest  forms  without  producing 
any  such  result." 

Mr.  Salter  then  records  a  series  of  cases  illustrative  of  the  vari- 
ous pathological  conditions  referred  to,  of  which  the  following  is  a 
brief  abstract : 

KEFLEX    AFFECTIONS. 

"  Facial  Neuralgia  from  Dentine  Excrescence  in  Pulp  Gavity. — 
A  woman  complained  of  severe  neuralgic  pains  obviously  connected 
with  an  upper  central  incisor.  The  pain  was  of  a  gnawing  character, 
abiding,  but  not  constantly  severe  ;  frequently  merely  a  conscious- 
ness of  the  presence  of  the  tooth,  but  at  other  times  sharp  and  dart- 
ing, flashing  up  the  side  of  the  face,  etc.,  through  all  the  branches 
of  the  superior  maxillary  division  of  the  fifth  nerve  of  that  side,  and 
considerably  augmented  by  sudden  pressure,  a  tap  upon  the  tooth, 
or  marked  change  of  temperature.  The  tooth  was  apparently  sound, 
though  somewhat  elongated  and  slightly  loose.  No  exostosis  was 
found  on  the  root  after  extraction,  but  on  making  a  section  of  it 
(vertical,  from  side  to  side)  an  excrescence  of  dentine  was  dis- 
covered growing  from  the  side  of  the  pulp  cavity,  and  occupying,  for 
a  short  space,  more  than  half  its  diameter.  The  removal  of  the 
tooth,  though  accompanied  with  a  violent  paroxysm  of  neuralgic 
agony,  was  followed  by  a  total  cessation  of  the  pain,  which  never 
recurred. 

"  Cranial  Neuralgia  from  an    Impacted   Canine   Tooth. — Miss 


726  ORAL  DISEASES  AND  SURGERY. 

B had  '  cut '  all  the  permanent  teeth  in  due  course  and  position, 

except  the  left  upper  canine,  the  proper  space  for  which  was  oblit- 
erated by  the  contact  of  the  lateral  incisor  and  first  bicuspis.  At 
the  time  jvhen  the  right  upper  canine  appeared,  a  hard  swelling  was 
noticed  in  the  palate,  on  the  left  side,  and  toward  the  front  of  the 
mouth,  and  this  slowly  developed  into  a  prominent  rounded  ridge, 
extending  obliquely  behind  the  left  incisors  and  left  first  bicuspis. 
No  inconvenience  was  felt  up  to  the  age  of  eighteen,  when  severe 
headache,  confined  to  a  spot  on  the  vertex  toward  the  left  side, 
attended  b}"  local  heat,  etc.,  temporarily  relieved  by  pressure,  made 
its  appearance.  This  headache,  which  was  recurrent  in  its  nature, 
lasted  until  the  patient  was  twenty-six,  no  actual  pain  being  felt  in 
the  impacted  tooth,  although  the  region  about  it  became  hot  and 
tender  upon  the  supervention  of  the  headache.  The  removal  of  the 
tooth  by  Mr.  Cartwright — an  operation  involving  much  chipping 
away  of  the  bony  cavity  in  which  it  was  imbedded — was  followed 
by  immediate  and  permanent  relief,  thirty  years  having  elapsed 
with  no  return  of  the  symptoms. 

"Intense  and  General  Neuralgia  from  Exostosis  on  Fangs  of 
Teeth. — Miss  B.  P.  had  gone  through  her  first  dentition  with- 
out trouble,  but,  on  account  of  some  crowding  on  the  advent  of  the 
permanent  teeth,  an  upper  and  lower  bicuspis  on  either  side  were 
extracted  to  make  room.  During  adolescence  she  was  attacked  by 
neuralgic  pains,  at  first  confined  to  branches  of  the  trigeminus,  but 
afterward  extending  to  the  arms,  legs,  etc.,  indeed,  nearly  the  whole 
body.  The  teeth,  though  apparently  sound,  had  a  tendency  to 
elongate  and  spread,  especially  the  upper  incisors,  with  which  the 
pain  was  at  first  chiefly  associated.  The  offending  teeth  always 
gave  pain  on  being  slightly  struck.  Mr.  Bell  removed,  from  time 
to  time,  the  teeth  most  obviously  connected  with  the  neuralgia,  in 
each  instance  with  temporary  relief  of  the  suffering,  and  in  every 
case  the  fangs  of  the  extracted  teeth  were  found  inc rusted  with 
nodular  exostosis,  though  the  teeth  themselves  were  free  from  caries. 
When  Mr.  Salter  saw  Miss  P.  (in  1851),  only  the  two  lower  left 
bicuspids  remained,  and  these  were  causing  a  continuance  of  the 
neuralgia,  which  ceased  after  their  removal.  On  the  fangs  of  both 
these  teeth  were  the  expected  nodules  of  exostosis.  This  patient  is 
stated  to  have  been  remarkably  anaemic,  the  gums  being  *  like  wax 
stained  of  the  palest  pink,'  and  the  alveoli  remaining  white  and 
bloodless  for  some  seconds  after  extraction  before  blood  enough 
oozed  from  the  broken  vessels  to  partially  fill  the  hollow  sockets. 


NEURALGIA.  7-21 

"  Neuralgia  of  the  Arm  from  Carious  Teeth  and  from  undue 
Presiiure  of  Artificial  Teeth. — In  the  case  of  Mrs.  E.,  caries  of 
aii}^  of  the  lower  teeth  on  the  left  side  has  been  immediately  followed 
by  severe  neuralgic  pain  at  the  spot,  small  and  circumscribed,  on  the 
front  of  the  left  forearm,  about  two  inches  below  the  line  of  flexion. 
Having  now  lost  all  her  teeth,  and  wearing  a  complete  artificial  set, 
whenever  the  lower  denture  hurts  the  jaw  on  that  side,  the  same 
symptom  is  manifested.  The  right  side  has  never  been  similarly 
aflfected. 

"  Chronic  Trismus  from  Impaction  of  Lower  Dens  Sapientise. — 
In  a  man  aged  twenty-three,  with  large  teeth  and  comparatively 
small  maxillary  bones,  the  lower  wisdom-teeth  were  imbedded,  and 
unable,' from  want  of  room,  to  come  into  place.  The  result  was  re- 
current pain  and  swelling  within  the  mouth,  followed  by  a  sudden 
attack  of  '  lock-jaw,'  apparently  caused  by  contraction  of  the  left 
masseter  muscle,  which,  after  four  months'  duration,  was  cured  by 
extraction  of  the  left  second  molar,  the  wisdom-tooth  being  out  of 
reach.  The  posterior  fang  of  the  extracted  tooth  was  much  eroded 
by  absorption. 

"  Wry-neck  from  Carious  Teeth  of  Loiver  Jaw. — A  young  woman 
whose  head  had,  for  more  than  six  months,  been  drawn  down  nenrly 
to  the  left  shoulder,  with  considerable  pain,  was  relieved  in  a  few 
days  by  the  removal  of  a  stump  and  a  partially  decayed  tooth  from 
the  left  side  of  the  lower  jaw. 

^'Epilepsy  from  Carious  Tooth. — A  boy,  aged  thirteen,  under  the 
care  of  Dr.  Ramskill,  had  frequent  attacks  of  epilepsy,  occun-ing 
about  seven  or  eight  o'clock  in  the  evening.  Examination  detected 
'  a  molar  tooth  considerably  decayed,  with  a  swollen  gum  around 
it,  and  partly  growing  over  into  the  cavity.'  It  was  not  very  tender 
to  the  touch,  nor  did  the  examination  give  rise  to  toothache.  The 
extraction  of  this  tooth  was  followed  by  cessation  of  the  fits. 

"  Tetanus  from  Mechanical  Irritation  of  the  Pxdp. — The  case  of 
a  gentleman  (quoted  from  Tomes^s  Dental  Surgery),  who,  having 
broken  off  a  front  tooth,  went  immediately  to  a  prominent  denti.st  in 
Paris  and  had  an  artificial  crown  pivoted  with  a  gold  peg  upon  the 
fang.  After  severe  pain  for  four  or  five  days,  trismus  set  in,  and  was 
soon  followed  by  tetanus  and  death. 

"Neuralgia  of  Face,  Neck,  and  Arm,  ivith  Partial  Paralysis  of 
the  latter,  from  Carious  Wisdom-Tooth. — Miss  W.  'was  suffer- 
ing from  constant  aching  pain  in  the  left  side  of  the  face  and  neck, 
and  in  the  left  arm.     The  pain  sometimes  became  intensely  severe. 


728  ORAL  DISEASES   AND   SURGERY. 

The  arm  had  lost  nearly  all  muscular  power.'  These  symptoms, 
after  resisting-  all  medical  treatment  for  two  years,  disappeared  in  a 
few  hours  after  the  removal  of  the  tooth. 

"Amaurosis  caused  by  Crowding  of  Teeth.— In  this  case  (re- 
ported by  Mr.  Hancock  in  the  Lancet  of  1859,  p.  80),  a  boy,  aged 
eleven,  whose  sight  had  been  previously  unimpaired,  found  upon 
waking  one  morning  that  he  was  entirely  blind.  About  a  month 
afterward  he  w^as  admitted  to  Charing  Cross  Hospital,  where  it  was 
discovered  that  his  teeth  were  '  much  crowded  and  wedged  together  ; 
the  jaws,  in  fact,  not  being  large  enough  for  them.'  Accordingly, 
two  permanent  and  four  milk  molar  teeth  were  extracted,  and  '  on 
the  same  evening  the  boy  could  distinguish  light  from  darkness,  and 
on  the  following  morning  could  make  out  objects.  From  this  time 
bis  sight  rapidly  improved,  and  he  was  dismissed  cured  on  the  28th 
(eleven  days  after),  the  only  treatment  beyond  the  removal  of  the 
teeth  being  two  doses  of  aperient  medicine.' 

"Dr.  AVatson  ('Lectures  on  Physic,'  fourth  ed.,  vol.  ii.  p.  351) 
mentions  a  very  similar  case.  But  the  blindness  was  confined  to 
one  eye ;  it  recurred  two  or  three  times,  and  was  on  each  occasion 
cured  by  tooth-extraction. 

"  Deaf ness  from  Carious  Teeth. — Mr.  Cattlin  reports  the  case  of 
a  lady  who  had  for  about  three  months  suffered  acute  pain  in  a 
diseased  right  lower  molar,  and  in  the  corresponding  ear  and  side 
of  the  neck,  and  who  had  been  deaf  for  four  days.  'The  inflamed 
tooth  was  extracted,  and  hearing  returned  within  an  hour  after  the 
operation.' 

"  Perverted  Nutrition  from  Dental  Ne?^vous  Irritation. — Under 
this  heading  three  cases  are  quoted  from  Mr.  Hilton's  work  ('  On 
the  Influence  of  Mechanical  and  Physiological  Rest,'  etc.),  in  which 
the  tongue  was  decidedly  furred  only  on  the  side  corresponding 
with  carious  or  painful  teeth  ;  one  in  which  the  hair  of  the  left 
temple  was  bleached  by  unilateral  neuralgia,  arising  from  a  carious 
molar  tooth;  and  one  in  which  ulceration  of  the  auditory  canal,  ac- 
companied with  offensive  discharges  from  the  ear,  and  enlargement 
of  one  of  the  cervical  glands,  was  traced  to  a  diseased  lower  molar 
on  the  same  side,  and  subsided  soon  after  the  extraction  of  the 
tooth." 

In  a  paper  on  "  Affections  of  the  Eye  from  Dental  Diseases,"  read 
before  the  Missouri  State  Medical  Association  by  Dr.  H.  Z.  Gill,  the 
following  instructive  case  is  cited  : 

"Mr.  F.  S.,  of  Illinois,  aged  thirty-three;  Irishman  by  birth  ;  farmer 


NEURALGIA.  729 

bj  occupation.  Patient  was  sent  to  me  by  a  medical  friend,  Feb.  12, 
1812.  The  history  of  the  case,  as  he  gave  it,  is  as  follows.  In  the 
early  part  of  the  winter  of  1870-11,  he  was  attacked  with  neuralgia 
of  the  head  and  face.  It  was  very  severe  at  times,  and  continued 
so  till  the  middle  of  the  summer  following.  The  neuralgia  affected 
both  sides  of  his  head,  and  his  vision  to  such  an  extent  that  he 
could  not  read.  After  the  pain  left  him,  in  the  middle  of  summer, 
his  sight  improved.  In  December,  1811,  he  was  again  attacked 
with  neuralgia  of  the  head  and  dimness  of  vision.  Before  he  came 
to  me  he  had  been  under  treatment  for  the  neuralgia,  but  I  believe 
nothing  had  been  done  to  relieve  the  amblyopia.  He  could  scarcely 
see  well  enough  to  go  on  the  street  with  safety  ;  could  make  out  No. 
16  of  Jaeger's  test-types.  He  had  been  able  to  sleep  but  little  for 
several  weeks,  on  account  of  the  severe  neuralgia.  Ophthalmoscopic 
examination  of  the  eye  showed  retinal  effusion  ;  the  retinal  artery 
was  very  indistinct.  The  painful  points  of  Valleix  (points  of  dou- 
loureux) were  well  mai'ked,  more  especially  on  the  left  side  of  the 
head.  The  patient  having  lived  in  a  region  of  country  where  ague 
at  times  prevails,  I  was  prepared  to  learn  that  his  treatment  had 
been  largely  antiperiodic.  I  now  sought  for  some  definite  source  of 
irritation,  inquiring  first  concerning  his  teeth,  to  which  his  answer 
was  that  he  had  no  toothache,  that  his  teeth  were  good.  I  then 
examined  them  by  inspection,  and  by  percussion  with  the  handle  of 
the  forceps,  yet  elicited  nothing,  except  that  the  teeth  were  not  at  all 
painful ;  but  there  was  decay  in  some  of  them  at  the  margin  of  the 
gum.  Having  myself  suffered  from  sensitive  dentine,  I  determined 
to  examine  more  carefully  and  minutely  in  the  decayed  spots.  When 
he  came  again,  in  a  day  or  two  afterward,  I  made  an  examination 
of  each  tooth,  and  was  rewarded  by  finding  what  appeared  to  be 
exposed  necrosis  of  the  alveolar  process  of  the  superior  maxillary 
bone  of  the  left  side,  but  which  proved  to  be  a  deposit  of  tartar,  as 
large  as  the  little  finger-nail,  attached  to  the  fangs  of  the  first  and 
second  molar  teeth,  the  gum  being  intact  around  the  necks  of  the 
teeth.  I  again  percussed  these  teeth  with  considerable  force  before 
the  patient  acknowledged  any  soreness  connected  with  them.  I 
advised  him  to  have  them  removed  immediately,  believing  them  to 
be  the  source  of  the  neuralgia,  and  this  latter  the  cause  of  the 
amblyopia. 

"  After  two  or  three  days'  consideration,  he  consented,  and  on  the 
16th  I  extracted,  at  the  first  sitting,  the  first  and  second  molars  and 
the  second  bicuspid.     On  examination  of  the  teeth  I  found  extensive 


730  ORAL  DISEASES  AND   SURGERY. 

nlceratioa  around  the  fangs  of  the  molars,  extending  in  some  degree 
to  the  second  bicuspis.  Believing  the  dens  sapientiae  not  to  be  im- 
plicated, it  was  not  extracted.  Three  or  four  daj^s  later,  I  extracted 
the  first  bicuspis,  believing  that  it  was  somewhat  involved.  Im- 
provement of  the  neuralgia  and  amblyopia  commenced  at  once. 
On  the  21st  he  read  No.  14  of  Jaeger,  and  on  the  24th  he  read  No. 
6.     His  general  condition  steadily  improved. 

"  March  4. — Reads  No.  2  with  some  difficulty.  "Went  home  March 
8  and  returned  March  13.  Has  had  pain  in  his  head  only  a  part  of  one 
day,  he  thinks  from  riding  in  the  wind  ;  reads  now  No.  2  with  consider- 
able ease.  Sleeps  well.  Called  twice  afterward,  and  went  home 
on  the  21st  of  March.  After  the  extraction  of  the  teeth,  he  called 
to  mind  the  fact  that  about  eight  years  since  he  had  received  a  blow 
on  his  jaw  while  breaking  a  colt.  The  face  was  swollen  for  a  few 
days  and  quite  painful,  but  all  uneasiness  soon  disappeared  ;  and  he 
had  entirely  forgotten  the  circumstance  until  reminded  of  it  by  the 
extraction  of  the  teeth. 

"  In  one  part  of  the  '  field  of  vision'  there  was  greater  defect 
than  in  the  remainder  ;  and  evidently,  from  the  appearance  of  the 
fundus,  there  was,  early  in  the  case  while  under  my  care,  retinal 
efi"usion.  The  specimens  of  teeth  are  preserved.  The  rapid  im- 
provement must  be  ascribed  almost  entirely  to  the  extraction  of 
the  teeth,  thus  removing  the  source  of  irritation." 

From  the  illustrations  given,  it  will  be  inferred  that  the  removal 
of  any  discovered  lesion  of  irritation  is  the  primary  indication  in 
every  case  of  neuralgia.  The  idea  has  been  advanced  that  there  is 
seldom  or  never  a  neuralgia  proper,  but  that  such  pain  is  simply  an 
expression.  It  is  unfortunately  the  case,  however,  that  too  often 
we  are  compelled  to  discover  our  weakness  in  a  search  after  causes, 
and  are  thus  rendered  unable  to  treat  a  case  scientifically,  but  are 
driven  to  empiricism.  Even  yet,  however,  we  may  render  more 
than  an  accidental  service;  and  the  principle  on  which  we  would 
found  such  treatment  is  that  of  soothing  and  quieting,  either  as  ap- 
plications would  refer  to  the  system  at  large,  or  to  the  particular 
part  involved.  Nervines,  where  there  is  general  nervous  disturb- 
ance, independent,  so  far  as  we  discover,  of  other  derangements, 
will  be  found  sometimes  to  act  very  happily.  The  tinctures  of  va- 
lerian and  gentian,  in  equal  proportion,  given  in  tablespoonful  doses, 
make  a  fine  combination.  Bromide  of  potassium,  where  it  seems 
necessary  to  keep  up  a  continuous  impression,  is  given  with  advan- 
tage in  doses  often  grains,  dissolved  in  a  wineorlass  of  water,  from 


1 


NEURALGIA.  731 

two  to  ten  times  a  day.  If  administered,  however,  in  a  paroxysm, 
forty  to  sixty  grains  will  be  found  not  too  much,  and  it  sometimes 
will  be  well  to  combine  with  it  small  doses  of  opium  or  morphia. 

R. — Potassii  bromidi,  gr.  xx  ; 

Morphias  acetatis,  gr.  ^  to  \,  according  to  severity  of  pain  ; 
Aquae,  5j.    M. 
To  be  repeated  as  required. 

Valerianate  of  zinc  is  a  favorite  preparation  with  many  practi- 
tioners. It  may  be  made  into  pills  with  conserve  of  rose,  or  any 
preferred  vehicle,  each  pill  to  contain  from  one-half  to  a  full  grain, 
to  be  given  twice  or  thrice  a  day. 

Tincture  of  Indian  hemp  is  prescribed  iu  doses  of  five  drops,  re- 
peated three  times  a  day. 

Where  there  is  disturbance  of  the  visceral  health,  it  has  been 
found  occasionally  successful  to  produce  rapid  but  moderate  saliva- 
tion. 

Aconite  made  into  quarter-grain  pills,  and  administered  cau- 
tiously, three  or  four  times  a  day,  is  recommended. 

Digitalis  in  tincture,  or  the  tincture  of  veratrum  viride,  in  condi- 
tions of  undue  circulatory  excitement,  exhibited  in  five-drop  doses 
until  such  excitement  is  subdued,  will  sometimes  quickly  relieve  the 
pain. 

Colchicum,  where  there  is  a  supposed  gouty  association,  may 
always  be  employed.     The  wine  of  the  root  is  the  best  preparation. 

In  rheumatic  neuralgia,  or  pain  associated  with  a  rheumatic  con- 
dition, the  following  formula  will  be  found  very  i-eliable  ;  certainly 
so,  if  some  other  existing  lesion  is  not  too  antagonistic : 

R. — Potassii  iodidi,  3ss  ; 

Extracti  belladonnas,  gr.  vj  ; 
Yini  colchici  radicis,  5ss; 
Tincturse  guiaici  ammoniats,  ^vj  ; 
Aquae  cinnamomi,  5vj.     M. 
Sig. — A  tablespoonful  to  be  taken  in  a  wineglass  of  water  three 
times  a  day  ;  if  it  should  purge,  five  drops  of  laudanum  may  be 
added  to  each  dose. 

Arsenic  is  frequently  used  with  decided  benefit.  It  may  be  ex- 
hibited in  granules  of  the  twentieth  of  a  grain  three  times  a  day.  It 
acts  well  in  cutaoeous  neural"ria. 


732  ORAL  DISEASES  AND  SURGERY. 

Donovan's  solution — the  liq.  hydrarg.  arsen.  et  iod. — is  a  favorite 
with  many  practitioners.  Dose,  five  drops  three  times  a  day,  avoid- 
ing salivation.    It  is  an  alterative,  having  a  variety  of  significations. 

In  all  cases  associated  with  lassitude  and  anaemia,  the  following 
may  be  prescribed : 


Or, 


Or, 


R. — Elixirii  gentiante  ferrates,  §vj. 
Sig. — Teaspoonful  four  times  a  day. 

R. — Tinctur^e  ferri  chloridi,  §j  ; 
Quinias  sulphatis,  5j-     M. 
Sig. — 15  to  20  drops  three  to  four  times  a  day. 

R. — Syrupi  ferri  pyrophosphatis,  5vj; 
Quiniae  sulphatis,  5j-     M. 
Sig. — Teaspoonful  four  times  daily. 

Opium  and  ether,  given  in  full  doses  before  a  paroxysm,  with  ten 
or  fifteeu  grains  of  quinine  administered  after  the  pain  has  ceased, 
will,  it  is  asserted,  at  once  make  an  impression,  and  frequently 
abridge  the  next  paroxysm.  Success  is  claimed  for  the  exhibition 
of  opium  to  the  production  of  narcotism.  Such  treatment  is  only, 
however,  commendable  as  an  occasional  expedient. 

Muriate  of  ammonia,  in  doses  of  half  a  drachm  three  or  four  times 
a  day,  has  been  given  with  advantage.  A  very  soothing  effect  is 
produced  by  placing  a  lump  of  the  ammonia  on  a  burning  coal  and 
thus  impregnating  the  atmosphere  of  a  room. 

Oil  of  turpentine  is  frequently  applauded  by  English  practitioners. 
It  may  be  given  in  doses  of  from  one-half  to  a  full  drachm. 

Chloroform,  or  chloroform  combined  with  camphor,  is  recom- 
mended.    A  formula  used  by  Dr.  Wood  is  as  follows: 

R. — Chloroformi,  f3ij  ; 
Caniphorae,  3j- 
Mix  with  the  yolk  of  an  egg  and  ^vj  of  water,  and  direct  a  table- 
spoonful  to  be  taken  every  half- hour,  every  hour,  or  every  two 
hours,  according  to  the  urgency  of  the  case,  until  relief  is  obtained, 
or  some  decided  effects  are  experienced  from  the  medicines,  either 
on  the  stomach  or  brain.    Or  the  chloral  hydrate  may  replace  this. 

Vermifuge  medicines  are  frequently  prescribed  with  benefit,  par- 
ticularly in  the  case  of  children  ;  parasites  frequently  keeping  up  an 


NEURALGIA.  733 

irritation,  although  presenting  no  definite  signs.  Of  these  medicines, 
one  of  the  very  best  is  the  combination  of  spigelia  and  senna. 

R. — Syrupi  spigelise  et  sennae,  ^iv. 
Sig. — Teaspoonful  doses  three  times   a  day.     Four  ounces  will 
commonly  be  found  enough  to  destroy  any  worms  which  may  be 
present  in  the  intestines. 

Cathartics  are  generally  indicated  in  spasmodic  attacks  of  neu- 
ralgia; especially  is  this  the  case  when  there  is  costiveness,  furred 
tongue,  sick  headache  or  stomach,  giddiness,  etc.  It  is  generally 
satisfactory  practice  to  precede  the  purgation  with  a  few  quarter- 
grain  doses  of  calomel.  The  character  of  the  purgative  is  to  be 
influenced  by  the  condition  of  the  patient.  Sulphate  of  magnesia  is 
generally  found  applicable.  Blue  mass,  colocynth,  and  jalap,  or  the 
compound  cathartic  pill,  I  have  mostly  found  objectionable.  Where 
febrile  disturbance  is  present,  particularly  do  I  think  this  combina- 
tion will  be  found  to  do  much  more  harm  than  good.  The  ordinary 
Seidlitz  powder,  repeated  three  or  four  times  within  the  day,  is  a 
very  happy  and  really  refreshing  medicine.  If  it  should  not  do  good, 
it  will  certainly  do  no  harm. 

Strychnine  is  an  empirical  anti-neuralgic  medicine  of  much  repu- 
tation. It  may  be  prescribed  in  quantities  of  two  grains,  divided 
into  eighty  pills,  one  to  be  taken  three  times  a  day. 

Of  local  remedies  there  is  a  great  variety.  A  formula  long  cele- 
l)rated  under  the  name  of  Rauque's  liniment,  is  as  follows: 

R. — Extract!  belladonnge,  9ij  ; 
^theris,  ^j  ; 

Aquae  lauro-cerasi,  §ij.     M. 
Sig. — Let  it  be  rubbed  on  the  part  and  saturated  flannel  be  ap- 
plied. 

The  endermic  application  of  morphia  is  a  common  practice.  The 
medicine  may  be  used  on  a  blistered  surface,  or  subcutaneously 
injected, — syringes  for  the  latter  purpose  being  made  by  all  instru- 
ment-makers. To  make  a  subcutaneous  injection,  it  is  only  neces- 
sary to  thrust  the  needle-point  of  the  syringe  into  the  rete  mucosura, 
or  it  may  be  passed  completely  beneath  the  skin  into  the  underlying 
cellular  structure. 

Hot  and  moist  applications  are  generally  found  of  much  service 
in  quieting  pain, — the  part  to  be  enveloped  in  old  and  loose  flannel, 


734  ORAL  DISEASES  AND  SURGERY. 

and  evaporation  prevented  by  an  investment  with  oiled  silk  or  other 
material. 

In  affections  of  the  fifth  pair,  Dr.  Richab,  of  Strasburg,  attributes 
great  good  to  one  grain  of  quinine  and  two  of  common  snuff,  intro- 
duced into  the  nostril  of  the  painful  side.  It  is  said  in  many  cases 
"  to  act  like  a  charm." 

Professor  Charles  Meigs  introduced,  several  years  back,  a  plan 
of  treatment  with  sulphuric  ether,  which  has  yielded  greater  tem- 
porary success  than  anything  else  I  have  ever  tried.  He  confused 
the  nerve-currents  by  taking  a  piece  of  sponge  saturated  with  ether, 
and,  by  a  continuous  but  irregular  round,  touching,  here  and  there, 
different  neighboring  surfaces,  until  the  pain  would  disappear.  If, 
for  example,  the  pain  was  in  the  forehead,  he  would  touch  over  the 
supraorbital  nerve,  over  the  infraorbital,  over  the  anterior  dental, 
over  the  facial,  over  the  cervical, — alternating  the  touches  to  these 
parts  for  a  period  varying  from  five  minutes  to  half  an  hour.  In 
most  cases  the  pain  will,  for  the  time,  be  relieved. 

Ci'easote,  much  diluted  in  simple  cerate,  is  sometimes  found  very 
useful  as  a  local  obtunder, — five  drops  of  creasote  to  the  ounce  of 
cerate  or  lard;  to  be  rubbed  over  the  affected  part,  little  bv  little,  until 
relief  is  obtained. 

Dr.  Kirby  directs  a  liniment  made  of  one  drachm  of  tincture  of 
aconite  to  seven  of  fresh  palm  oil,  or  with  two  ounces  of  camphor 
liniment, — a  half  drachm  of  the  former,  or  double  the  quantity  of 
the  latter,  to  be  rubbed  in  twice  or  thrice  a  day,  according  to  its 
effects.  It  must  be  watched,  however,  as  the  medicine  is  cumula- 
tive; if  its  poisonous  effects  appear,  stimulants  are  to  be  given. 

Dr.  Grave's  neuralgic  plaster  is  compounded  as  follows: 

B. — Pulveris  opii,  3ij  ; 
Camphorse,  5ss.; 
Picis  Burgundicce,  q.  s.     M. 
Stupe  the  parts  with  warm  water  before  applying  it. 

Cazenave's  pomade  is  thus  made  : 

B.- — Chloroformi,  5j  ; 

Potassii  cyanidi,  S'jss; 
Adipis,  §iij  ; 
Cerse  albae,  q.  s. 
Rub  into  the  part  a  piece  of  the  ointment  the  size  of  a  pigeon's 
e^g,  and  cover  with  oilskin. 


NEURALGIA.  735 

"  Canea  treated  successfully  by  the  Spine-bag.  By  Jolin  Chap- 
man, M.D.,  M.R.C.P.,  M.S.C.S.,  Physician  to  the  Farringdon  Dis- 
pensary.— The  cure  of  neuralg-ia,  whether  the  disease  be  treated 
by  drugs  given  internally,  or  by  application  of  various  kinds  at  the 
seat  of  pain,  or  by  the  two  methods  conjointly,  is  confessedly  almost 
always  difficult,  and  iu  a  large  proportion  of  cases  impossible.  The 
cases  reported  below  have  been  treated  by  a  method  altogether  new. 
By  stating  each  case  with  extreme  brevity,  I  am  enabled  to  present 
at  one  view  within  a  small  compass  the  results  of  several  experi- 
ments ;  and  I  do  this  in  the  hope  that  they  may  produce  such  an 
impression  on  the  minds  of  professional  readers  as  may  impel  them 
to  acquaint  themselves  with  the  pathological  and  therapeutical  prin- 
ciples of  which  these  results  are  an  expression.  I  shall  hereafter 
publish  an  exposition  of  these  principles,  illustrated  by  reports  of 
cases  in  extenso,  and  shall  then  give  a  full  description  of  the  treat- 
ment adopted. 

"  1.  Facial  Neuralgia. — T.  H.,  a  gentleman,  aged  thirty-five,  who 
had  been  suffering  during  the  previous  fortnight,  requested  my 
advice  March  18,  1865.  He  was  in  great  pain,  which  had  been 
continuous  from  the  previous  day,  and  which  had  wholly  deprived 
him  of  sleep.  The  pain  was  chiefly  on  the  right  side  of  the  face 
and  head ;  but  during  the  morning  preceding  my  visit  the  left  side 
had  become  invaded.  The  affected  parts  were  very  tender,  and 
somewhat  swollen.  The  head  was  rather  hot,  the  face  flushed,  the 
tongue  thinly  coated  with  whitish  fur;  pulse  92,  full  and  strong. 
Several  medicines  prescribed  by  two  physicians  in  succession  had 
proved  of  no  avail. 

"I  applied  a  ten-inch  spinal  water-bag,  containing  water  at  130° 
F.,  to  the  cervico-dorsal  region,  and  shortly  afterward  left  the  pa- 
tient's room.  Within  half  an  hour  I  returned,  when  I  found  him 
asleep.  The  treatment  was  continued  for  two  days  by  means  of 
heat;  afterward  I  used  ice  (at  first  in  the  lumbar  region)  ;  and  from 
the  time  he  first  fell  asleep  he  continued  free  of  pain,  which  has  not 
since  returned. 

"2.  Facial  Neuralgia. — Fraulein  S.,  aged  about  twenty-five,  con- 
sulted me  February  3,  1867,  on  account  of  neuralgia  affecting  the 
infraorbital  and  dental  branches  of  the  trifacial  nerve.  The  pain 
was  not  confined  to  one  side  of  the  face,  but  was  sometimes  most 
acute  on  one  side,  sometimes  on  the  other ;  it  increased  at  evening, 
and  kept  her  awake  the  greater  part  of  each  night.  !She  had  been 
suffering  in  this  wav  for  about  three  weeks  before  I  saw  her.     Her 


736  ORAL  DISEASES  AND   SURGERY. 

general  health  was  good.     The  affected  parts  presented  no  trace  of 
hypersemia. 

"  She  was  treated  by  means  of  ice,  and  experienced  almost  imme- 
diate relief.  After  three  days  of  treatment  she  felt  and  slept  very 
much  better;  and  before  the  end  of  the  fifth  day  the  pain  had  wholly 
ceased.  Nearly  a  year  afterward  she  told  me  that  it  had  never 
returned. 

"  3.  Facial  Neuralgia. — Mademoiselle  M.,  aged  twenty,  consulted 
me  in  August,  1S67,  when  she  was  suflfering  from  acute  facial  neural- 
gia, the  chief  foci  of  which  were  the  infraorbital  foramen,  and  the 
mental  foramen  of  the  right  side.  The  extreme  pain  came  on  in  fits, 
sometimes  at  8  a.m.,  sometimes  at  2  P.M.,  but  between  the  paroxysms 
the  face  continued  to  ache,  and  at  times  the  patient  had  pain  at  the 
back  of  the  head.  She  had  suffered  in  this  way  about  a  fortnight 
before  coming  to  me,  and  had  several  similar  attacks  during  the 
preceding  year. 

"  The  treatment  consisted  in  the  application  of  the  double-col- 
umned hot-water  bag.  The  malady  was  immediately  subdued  :  no 
distinct  paroxysm  occurred  after  the  first  application  of  heat ;  all 
pain  rapidly  and  completely  subsided,  and  since  that  date  has  not 
returned. 

"  4.  Dental  Neuralgia. — A.  W.  B.,  a  Russian  gentleman,  suffer- 
ing from  dental  neuralgia,  consulted  me  in  September,  1867.  The 
malady  was  chiefly  confined  to  the  teeth  of  both  upper  and  lower 
jaw,  but  no  particular  tooth  or  teeth  seemed  to  be  especially  affected. 
The  pain  was  intermittent,  and  so  severe  as  to  interfere  seriously 
with  the  patient's  daily  occupation.  No  cause  of  the  disorder,  which 
had  continued  some  weeks,  could  be  discovered,  and  the  face,  so 
far  from  showing  any  sign  of  hyperaemia  over  the  seat  of  pain, 
seemed  cooler  than  normal.  In  the  course  of  the  first  day  of  treat- 
ment by  means  of  the  spinal  ice-bag,  the  pain  was  completely  sub- 
dued ;  the  cold  was  persisted  in  for  some  lime,  and  during  the 
remainder  of  the  patient's  stay  in  England  he  continued  free  from 
suffering. 

"  5.  Dental  Neuralgia. — H.  E.,  female,  aged  twenty-one,  suffering 
from  violent  and  continuous  pain,  spreading  over  the  teeth  and  gums 
of  both  the  upper  and  lower  jaw,  consulted  me,  January  H,  1868. 
The  pain  was  most  intense  in  the  lower  jaw  and  on  the  left  side  ; 
she  had  intense  headache  also.  The  forehead  and  cheeks  were 
notably  hotter  than  normal,  and  she  complained  of  great  heat  in  the 
roof  of  the  mouth  as  well  as  in  the  gums, — which  were  swollen  and 


NEURALGIA.  737 

sore.  During  the  previous  week  she  had  had  several  teeth  stopped 
with  gold  ;  one  of  them  became  most  especially  painful,  and  there 
was  threatening  of  an  abscess  at  its  root. 

"The  treatment  consisted  in  the  application  of  cold  across  the 
occiput,  and  of  heat  over  the  ilio-spinal  region, — in  the  first  instance 
separately,  and  afterward  simultaneously.  The  pain  was  speedily 
and  completely  annulled  ;  it  recurred,  and  was  again  annulled  by 
the  same  method  on  several  occasions.  The  patient  volunteered 
the  statement  that  during  the  application  of  the  heat  her  mouth 
became  perceptibly  cooler. 

"•6.  Facial  and  Brachial  Neuralgia. — Mary  A.  T.,  aged  forty-four, 
first  consulted  me  at  the  Farringdon  Dispensary,  December  28, 1861, 
when  she  was  suffering  from  neuralgia  of  the  right  side  of  the  head, 
face,  and  neck,  and  along  the  right  shoulder  and  arm,  extending  to 
the  fingers.  The  right  half  of  the  tongue  was  also  afifected.  The 
pain,  which  was  exactly  limited  to  the  median  line,  was  described 
by  the  patient  '  like  as  if  something  is  pulling  the  flesh  off  the 
bone,  it's  so  dreadful,  and  sometimes  as  if  the  parts  were  screwed 
up  in  a  vice.' 

"  She  was  treated  by  means  of  ice  applied  along  the  whole  spine. 
She  improved  immediately  and  rapidly,  and  as  early  as  January 
15,  informed  me  that  she  had  not  had  'a  bit  of  neuralgia'  during 
the  whole  of  the  preceding  week.  Up  to  this  date  (February  29) 
the  pains  have  not  returned." 

Facial  Neuralgia  from  Exposed  Tooth  Pulp. — Mrs.  H.  had  suf- 
fered for  several  years  with  frequent  intense  and  persistent  facial 
neuralgia;  had  been  under  the  care  of  four  physicians  ;  taken  most 
of  the  sedative,  antispasmodic,  tonic,  and  alterative  remedies  which 
could  be  named ;  had  been  forbidden  to  go  out  of  the  house  after 
sundown  ;  was  not  allowed  to  put  her  hands  in  cold  water,  etc. 

When  consulted  in  reference  to  her  condition,  I  requested  that  a 
thorough  examination  of  her  teeth  should  be  made  by  a  competent 
dentist,  with  a  view  of  ascertaining  if  the  trouble  did  not  originate 
there.  This  was  acceded  to,  but  reluctantly,  because  no  pain  had 
been  felt  in  the  teeth.  It  was,  therefore,  with  some  show  of  gratifica- 
tion that  I  was  assured  subsequently  that  the  teeth  were  all  sound. 
I  begged,  as  a  special  favor,  another  and  more  thorough  examination, 
which,  very  much  to  my  gratification,  discovered  an  exposed  pulp. 
This  having  been  treated,  the  neuralgia  disappeared,  and  has  not 
since  returned,  a  period  of  two  years  having  elapsed. — (J.  W.  While.) 

Surgical  Interference  by  Operation. — Interference  by  direct 

47 


738  ORAL  DISEASES  AND   SURGERY. 

operation  has  not,  as  a  general  thing,  been  so  satisfactory  as  could 
be  desired. 

Operative  surgery  in  neuralgia  refers  to  the  division  or  resection 
of  nerves.  In  facial  neuralgia,  where  such  interference  is  most 
frequently  practiced,  the  history  of  the  majority  of  cases  has  cer- 
tainly not  made  sufficient  offset  to  balance  the  risks  incurred.  It 
is  undoubtedly  true  that  cases  occur  where  it  would  seem  that 
nothing  else  can  be  done.  But  when  sections  are  made  of  healthy 
nerve-cords  one  should  be  well  satisfied  that  he  has  an  otherwise 
irremediable  condition  in  the  nerve-substance  external  to  his  line  of 
section.  Following  the  history  of  reported  cases  from  nerve-section, 
the  inquirer  will  often  have  occasion  for  surprise  at  the  difference 
between  the  actual  and  the  descriptive  results.  And  this  must 
continue  to  be  the  case  so  long  as  operations  are  made  without 
proper  diagnostic  perceptions;  not  that  operative  means  are  to  be 
discountenanced,  but  it  ma}^  with  propriety  be  assumed  that  a  sur- 
geon should  find  the  indorsement  of  operative  means  only  in  a  diag- 
nosis which  discovers  to  him  the  true  seat  of  the  lesion  of  offense. 
As  an  example  of  the  heroic  practice  occasionally  pursued  in  this 
direction,  both  in  our  own  country  and  in  Europe,  the  following 
may  be  cited  from  a  report  in  Gurer's  "  Progress  of  Surgery" 
(Berlin,  1863-65).  The  patient,  a  woman,  submitted  to  various 
sections  of  the  supra-  and  infraorbital  nerves  for  a  period  of  five 
years,  but,  finding  no  relief,  repeated  extirpations  of  the  cicatrices 
were  made,  the  common  carotid  tied,  the  ascending  ramus  of  the 
lower  jaw  trephined,  and  the  inferior  dental  nerve  exsected,  to- 
gether with  the  mylo-hyoid  and  lingualis,  causing  necrosis  of  the 
bone,  which  had  to  be  removed  to  the  articulation.  Five  months 
later  the  neuralgia  returned,  when  the  infraorbital  nerve  was  ex- 
sected nearly  to  the  foramen  rotundum.  This  was  followed  by  an 
osteoplastic  resection  of  the  upper  part  of  the  superior  maxillary 
bone,  but  saving  the  alveolar  process  as  in  Langenbeck's  operation. 

In  another  German  case  (  Vierteljahraschrift  fur  die  practische 
Heilkmide)  the  powerful  galvano-caustic  apparatus  of  Middeldorpff's 
was  employed,  at  once  destroying  everything  in  the  spheno-max- 
illary  fossa,  being  followed  by  a  gush  of  blood  from  the  internal 
maxillary  artery,  which  instantly  filled  the  orbit  and  all  surrounding 
tissues. 

For  operations  practiced,  and  the  mode  of  performing  them,  see 
chapter  on  Resections. 

Anomalous  Nervoxis  Disturbances  from  Diseased  Teeth. — As  a 


NEURALGIA.  739 

continuation  of  the  subject  of  reflex  or  associate  disturbances,  it  may 
not  be  without  advantage  to  add  the  following  series  of  clinical  ob- 
servations, abstracted  from  various  journals  which  from  time  to  time 
have  come  under  the  observation  of  the  author : 

"Dr.  B.,  a  dentist,  consulted  me  in  reference  to  his  eyes,  which 
'would  not,'  as  he  expressed  it,  'focus  together:'  could  see  dis- 
tinctly with  either  eye,  but  not  with  both  at  once;  was  unable,  in 
consequence,  to  practice  his  profession  ;  had  consulted  several  phy- 
sicians ;  been  blistered,  cupped,  and  had  various  applications  made 
to  the  eye,  but  it  was  gradually  growing  worse.  The  pupil  of  the 
right  eye  was  very  much  enlarged. 

"I  pronounced  a  carious  and  diseased  first  superior  molar  to  be 
the  exciting  cause.  It  was  extracted,  with  almost  immediate  relief 
and  a  permanent  cure." — {Dr.  J.   W.   White.) 

Facial  Paralysis. — Dr.  Chas.  Bacon  reported  to  the  New  York 
State  Medical  Society  the  following  interesting  case  of  facial  paral- 
ysis : 

"  The  paralysis  occurred  first  on  the  left  side,  and  was  caused 
probably  by  irritation  of  the  facial  or  seventh  nerve,  by  the  erup- 
tion of  the  dens  sapientise  of  the  upper  maxilla  of  the  same  side, 
and  exposure  to  cold.  The  swollen  gum  was  freely  excised,  mus- 
tard pediluvia  were  employed,  active  catharsis  procured,  and  the 
camphorated  liniment  with  tincture  of  opium  applied  to  the  mas- 
toid region  and  to  the  angle  of  the  jaw,  and  subsequently  electro- 
magnetism  to  the  same  region  was  resorted  to,  followed  by  a  blister 
to  the  mastoid  region,  the  denuded  surface  produced  by  it  being 
sprinkled,  twice  a  day  for  two  days,  with  one-eighth  of  a  grain  of 
strychnine,  and  then  a  few  doses  (fifteen  drops)  of  a  solution  of 
three  grains  of  strychnine  in  3j  of  alcohol  were  taken.  At  the  end 
of  some  seventeen  months  the  paralysis  had  entirely  disappeared. 
For  about  ten  months  the  patient  enjoyed  uninterrupted  good  health, 
when  he  was  again  attacked  with  facial  palsy  of  the  right  side. 
The  gum  of  this  side  was  swollen,  A  treatment  somewhat  similar 
to  that  pursued  in  the  first  attack  was  directed.  At  the  period  when 
the  report  was  drawn  up,  about  four  weeks  from  the  date  of  tlie 
second  attack,  the  paralysis  was  lessened  in  extent,  and  the  general 
health  of  the  patient  was  good.  The  gum  was  less  swollen,  but  the 
tooth  had  not  yet  made  its  appearance." 

la  Mr.  Waite's  little  book  on  "  The  Gums,"  p.  29,  are  recorded 
ten  cases  of  paralysis  from  pressure  upon  the  maxillary  nerve,  one 
being  of  the  leg,  the  other  of  the  arm. 


740  OBAL  DISEASES  AND  SURGERY. 

"Neuralgia  loith  Deafness,  cured  instantaneously  by  the  Extrac- 
tion of  a  Tooth. — M.  Ed.  Vautier  records  (Gazette  des  Hopitaux)  a 
case  of  such  character.  The  subject  of  it  was  a  very  nervous,  slender 
woman,  who  had  suffered  for  about  four  months  with  intense 
neuralgic  pains,  radiating  through  almost  all  the  teeth,  and  also 
the  muscles  of  the  anterior  region  of  the  left  side  of  the  head. 
There  was  constant  lachrymation  of  the  left  eye,  and  from  the  mo- 
ment of  the  attack  complete  deafness  in  the  ear  of  the  same  side. 
A  number  of  physicians  had  been  consulted,  and  sulphate  of  quinia, 
flying  blisters,  and  atropia,  in  succession,  tried  without  giving 
relief 

"When  seen  by  Dr.  B.,  she  was  suffering  severely;  had  long  been 
deprived  of  sleep,  and  could  not  chew  her  food.  The  teeth  were 
examined  with  care,  but  no  one  could  be  found  carious.  The  wisdom- 
tooth  on  the  left  side  seemed,  however,  slightly  painful  on  being 
touched,  and  loose.  She  was  advised  to  have  this  tooth  extracted, 
but,  with  some  temper,  refused.  However,  some  days  afterward,  her 
physician  again  advising  it,  she  consented,  and  the  tooth  was  ex- 
tracted by  M.  Vautier.  The  pains  at  once  ceased,  and  her  hearing 
was  restored.  A  month  has  since  elapsed  without  any  return  of  her 
complaint.  She  seems  to  be  permanently  cured." — {Dental  Cosmos.) 

"  Cases  of  Convulsions  arising  from  Carious  Teeth. — St.  Bar- 
tholomew's Hospital. — Notes  furnished  by  Mr.  Alfred  Coleman  : 

"Case  I. — L.  C.  G.,  aged  seven  years,  a  moderately  healthy-look- 
ing child  up  to  the  age  of  four  years  and  a  half,  when  he  had  scar- 
latina severely,  followed  by  glandular  swellings.  About  four  months 
since  he  was  observed  to  avoid  using  his  fingers,  and  would  attempt 
to  take  up  a  cup  between  the  backs  of  his  two  hands,  for  which  his 
mother,  thinking  it  was  a  childish  trick,  always  scolded  him,  and 
tried  to  make  him  take  it  up  in  the  proper  way,  but  without  much 
success.  Fancying  his  right  arm  was  diminishing  in  size,  she  took 
him  to  Mr.  Coote,  who  sent  him  to  Mr.  Coleman  to  examine  his 
mouth.  This  was  on  a  Saturday.  In  the  afternoon  of  the  same 
day,  after  having  been  seen  by  Mr.  Coleman,  the  child  was  attacked 
with  a  fit  of  what  his  mother  described  as  shivering  in  the  right 
arm,  the  arm  and  fingers  being  drawn  up  as  well  as  convulsed;  his 
speech  also  seemed  affected.  Shortly  afterward,  this  was  succeeded 
by  another  tit  of  the  same  character,  which  commenced  with  a  feel- 
ing of  pins  and  needles  in  the  right  shoulder,  extending  to  the  arm 
and  hand.  From  the  Saturday  to  the  Sunday  evening  inclusive  he 
had  ten  such  atta,cks.    On  the  Monday  he  had  an  epileptic  fit,  which 


NEUBALGIA.  741 

lasted  two  hours,  soon  afterward  followed  by  another,  which  did  not 
last  so  long. 

"  Wednesday. — The  child  has  had  no  more  epileptic  fits ;  but  the 
lesser  seizures  still  continue,  occurring  very  frequently.  He  appears 
much  alarmed  at  them.  His  mouth  and  cheek  are  drawn  up  during 
a  fit,  and  he  cannot  speak;  but  says,  'Mother,  it  is  going,'  as  the 
attack  is  leaving  him.  On  this  day  Mr.  Coleman  extracted  his  four 
temporary  second  molar  teeth,  all  of  which  were  decayed,  but  had 
given  him  little  or  no  pain. 

"May,  1861. — Has  remained  perfectly  free  from  the  before-men- 
tioned seizures  since  the  removal  of  the  teeth  until  within  the  last 
two  days,  during  which  he  has  had  seven  slight  attacks.  One  of 
the  first  temporary  teeth  was  found  to  be  carious,  and  it  Nyas  removed 
about  a  week  after  this.  His  mother  called  and  stated  that  he  had 
one  very  slight  attack  since  the  removal  of  the  tooth  ;  she  promised 
to  bring  him  should  a  second  occur,  but  neither  mother  nor  child 
has  been  seen  since  that  time. 

"  Case  II. — M.  J.,  aged  about  twenty-three  years  ;  is  healthy-look- 
ing, and  enjoys  very  good  health;  suffers  much  from  toothache,  and 
during  the  tits  has  a  tingling  sensation  in  the  palms  of  his  hands 
and  soles  of  his  feet,  but  especially  in  the  left  arm.  Several  of  his 
teeth  were  decayed,  but  not  so  much  so  as  to  require  removal ;  they 
were  filled  with  gold,  since  which  he  has  had  no  return  of  pain  or 
the  accompanying  sensations." 

"Amaurosis  consequent  on  Acute  'Abscess''  of  the  Antrum,  pro- 
duced by  a  Carious  Tooth. — By  S.  J.  A.  Salter,  M.B.,  F.L.S.  Read 
before  the  Royal  Medical  and  Chirurgical  Society. — The  case  upon 
which  this  paper  was  based  was  one  of  unusual  severity,  and  of 
exceptional  complications.  The  patient,  a  young  woman  twenty- 
four  years  of  age,  was  attacked  with  violent  toothache  in  the  right 
upper  first  molar,  which  was  followed  by  enormous  swelling  of  the 
side  of  the  face,  and  intense  pain.  The  eyeball  then  became  pro- 
truded, and  she  soon  after  perceived  that  the  eye  was  blind.  Shortly 
after  the  establishment  of  these  symptoms,  'abscess'  of  the  antrum 
pointed  at  the  inner  and  then  at  the  outer  canthus,  and  a  large  dis- 
charge of  pus  at  both  orifices  followed  ;  these  orifices  soon  closed, 
and  the  general  symptoms  of  the  part  continued  unchanged, — the 
swelling  of  the  face,  protrusion  of  the  globe,  and  blindness.  This 
state  of  things  lasted  for  about  three  weeks,  when  the  patient  was 
sent  to  Guy's  Hospital,  and  admitted. 

'At  this  time  the  patient  exhibited  hideous  disfigurement  from 


742  ORAL  DISEASES  AND   SURGERY. 

swelling  of  the  face,  oedema  of  the  lids,  and  lividitj  of  the  surround- 
ing integument.  Upon  examining  the  mouth,  it  was  found  that  the 
carious  remains  of  the  first  upper  right  molar  appeared  to  be  asso- 
ciated with  and  to  have  caused  the  disease.  Together  with  the 
other  contiguous  carious  teeth,  this  was  removed,  and  led,  by  an  ab- 
sorbed opening,  through  the  floor  of  the  antrum.  The  hemorrhage 
which  followed  the  operation  was  discharged  partly  through  the 
nose  and  partly  through  the  orifices  in  the  cheek,  as  well  as  from 
the  tooth-socket,  showing  a  common  association  of  these  openings 
with  the  antrum.  The  condition  of  the  eye  constituted  the  most 
important  symptom,  and  the  most  distressing.  The  sight  was 
utterly  gone  ;  the  globe  prominent  and  everted.  There  was  general 
deep-seated  inflammation  of  the  fibrous  textures  of  the  eye.  The 
pupil  was  large  and  rigidly  fixed  ;  it  did  not  move  co-ordinately  with 
the  other  under  any  circumstances.  Some  abatement  of  the  symp- 
toms followed  the  extraction  of  the  tooth  ;  but  it  was  soon  found  that 
there  was  a  considerable  sequestrum  of  dead  bone,  which  was  re- 
moved. The  necrosis  involved  the  front  part  of  the  floor  of  the 
orbit,  the  upper  cheek  portion  of  the  superior  maxilla,  with  the  infra- 
orbital foramen,  and  a  large  plate  of  bone  from  the  inner  (nasal) 
wall  of  the  antrum.  The  removal  of  the  dead  bone  was  followed 
by  the  immediate  and  complete  cessation  of  all  inflammator}^  symp- 
toms; but  the  eye  remained  sightless,  and  the  pupil  rigidly  fixed. 
About  five  weeks  after  the  removal  of  the  dead  bone,  it  was  noticed 
that  the  pupil  of  the  affected  eye  moved  with  that  of  the  other, 
under  the  influence  of  light,  though  vision  in  it  had  not  returned. 
The  eye  was  frequently  examined  at  this  stage  with  the  ophthalmo- 
scope. All  the  structures,  including  the  retina,  appeared  healthy, 
except  the  termination  of  the  optic  nerve,  which  was  perfectly 
white  and  anaemic,  while  that  of  the  other  eye  was  pink  and 
natural. 

"  The  author  referred  to  two  other  cases  essentially  similar  to  his 
own.  The  first  (unpublished)  occurred  in  the  practice  of  Mr.  Pol- 
lock, of  St.  George's  Hospital.  The  patient  had  intense  inflamma- 
tion of  the  entire  maxillary  region  on  one  side,  caused  by  a  carious 
tooth.  It  implicated  the  whole  face  and  the  contents  of  the  orbit, 
but  was  not  attended  by  'abscess'  of  the  antrum  or  necrosis  of  bone. 
The  inflammation  completely  ceased  on  the  removal  of  the  tooth, 
but  the  sight  was  permanently  lost;  the  pupil  was  at  first  fixed,  but 
afterward  moved  with  that  of  the  other  eye. 

"Another  example,  closely  resembling  these,  was  published  by 


NEUBALGIA.  743 

Dr.  Bi-uck,  in  Casper's  '  WochenschrifL'  for  1851.     It  was,  however, 
more  chronic,  and  the  loss  of  vision  was  only  temporary. 

"  The  author  concluded  his  paper  by  suggesting  that  the  serious 
ophthalmic  symptoms  depended  on  the  nerves  of  the  eye  being  in- 
volved in  a  plastic  inflammation  in  their  course,  external  to  the  skull 
and  before  their  distribution ;  that  the  optic  nerve  was  permanently 
damaged,  as  shown  by  the  permanent  blindness;  and  that  the  third 
nerve  was  temporarily  implicated,  as  shown  by  the  temporary  fixed- 
ness of  the  pupil ;  and  the  eversion  of  the  eye  from  the  first  seemed 
to  indicate  that  the  sixth  nerve  was  less  or  not  at  all  involved. 
Finally,  the  author  left  it  an  open  question  whether  the  anaemia  of 
the  optic  nerve,  as  displayed  by  the  ophthalmoscope,  is  to  be 
looked  upon  as  a  cause  or  consequence  of  its  suspended  function." — 
{Lancet.) 

Sympathetic  Action. — In  the  course  of  an  article  on  "Amaurosis 
and  other  Disorders  of  the  Eye,  resulting  from  Injury  of  the  Terminal 
Branches  of  the  Fifth  Pair  of  Nerves,"  in  the  American  Journal  of 
the  Medical  Sciences  for  July,  Dr.  D.  Lente  gives  the  following 
interesting  observations  upon  the  sympathetic  relations  of  the  teeth 
and  eye  :  "  Middlemore  says  '  amaurosis  may  arise  during  the  period 
of  dentition  ;  it  may  take  place  from  the  irritation  of  a  carious  tooth  ; 
from  laceration  or  other  injury  of  the  supraorbital  nerve.'  He  relates 
a  case  in  which  Mr.  Howship  removed  an  encysted  tumor  from  the 
scalp,  which  produced  '  marked  and  permanent  improvement  in 
vision.''  Another  case,  in  which  M.  Demours  removed  a  tumor  from 
the  neighborhood  of  the  eye,  and  thus  produced  amaurosis.  Another 
from  the  Edinburgh  Medical  and  Surgical  Journal,  '  which  would 
appear,'  he  says,  'to  prove  that  wounds  of  the  infraorbital  nerve 
may  restore  the  sight  of  an  eye  which  has  long  been  lost  from  an 
amaurotic  affection.'  '  A  man  was  affected  with  perfect  gutta  serena 
of  the  right  eye,  and  had  the  sight  of  the  eye  restored,  he  thinks, 
in  consequence  of  receiving  a  smart  blow  in  the  neighborhood  of  the 
infraorbital  nerve  of  the  right  side  of  the  face.'  Another  still  more 
striking  case,  in  which  a  person  received  'a  wound  just  above  the 
right  eyebrow  from  a  piece  of  glass,  which  was  removed  imme- 
diately after  the  accident.'  When  the  wound  had  healed,  '  the  sight 
of  the  right  eye  was  very  nearly  lost ;  he  has  had  a  painful  sensation 
in  the  neighborhood  of  the  cicatrix,  and  a  singular  sense  of  creeping, 
and  pinching  and  quivering  of  the  upper  eyelid  and  the  integuments 
of  forehead.'  '  I  made  a  free  incision  of  the  cicatrix  down  to  the  bone, 
and  all  uneasiness  at  once  ceased,  and  the  eye,  shortly  after,  assumed 


744  ORAL  DISEASES  AND   SURGERY. 

its  healthy  character  and  functions,  and  vision  was  permanently 
restored.^  Lawrence,  after  relating  two  or  three  cases  of  amaurosis 
following  wounds  and  the  formation  of  cicatrices  over  the  brows, 
remarks,  '  It  is  still  a  matter  of  doubt  whether  injuiy  of  the  frontal 
nerve  may  cause  amaurosis.'  And  yet,  he  adds,  'injury  or  other 
irritation  of  the  trigeminus  may  bring  on  impaired  vision  or  amau- 
rosis.' '  The  sympathy  between  the  trigeminus  and  the  immediate 
nervous  apparatus  of  vision  affords  the  only  explanation  of  some 
apparently  obscure  cases,  in  which  amaurosis  seems  to  have  de- 
pended on  a  carious  tooth,  or  on  some  other  local  affection  seated 
in  the  head.' 

"  The  following  remarks  by  Marshall  Hall  were  reported  in  the 
London  Lancet:  'These  experiments,'  alluding  to  those  made  by 
Magendie,  'are  not  the  only  evidence  we  possess  of  the  influence 
of  the  fifth  pair  on  vision.'  'In  an  interesting  case  under  my 
own  care,  a  partial  amaurosis  of  the  right  eye  has  arisen  appar- 
ently from  the  caries  of  the  upper  canine  tooth  of  the  right  side.' 
It  was  augmented  by  unsuccessful  efforts  at  extraction.  It  has  not 
ceased,  however,  since  extraction  was  effected.  '  These  facts,'  says 
he,  speaking  of  this  and  other  cases,  '  with  the  similar  results  from 
wounds  or  tumors  of  the  supraorbital  branch  of  the  fifth,  appear  to 
me  to  confirm  the  extraordinary  experiments  of  Magendie.'  Hennen 
says,  'I  have  met  with  one  or  two  cases  of  amaurosis  from  wounds 
of  the  supraorbital  nerve.'  '  Scarpa,'  he  says,  '  doubts  of  the  pos- 
sibility of  the  cure  of  amaurosis  from  this  cause,  and  mentioiis  Val- 
salva's case  as  the  only  one  on  record.'  Mr.  Hey,  however,  states 
another  in  the  3Iedical  OhaervationH  and  Inquiries,  vol.  v.  M. 
Larrey  mentions  another.  Vicq  d'Azyr,  who  gives  a  case  of  amau- 
rosis from  a  wound  of  this  nerve,  in  the  Histoire  de  la  Societe 
Royale  de  Medecine,  annee  1T76,  says  he  has  'since  divided  this 
nerve  in  quadrupeds,  but  without  producing  any  such  effect.' 

"  That  defective  vision  may  result  as  the  direct  consequence  of 
irritation  of  the  terminal  branches  of  the  fifth  pair  may  also  be  in- 
ferred from  the  effects  of  remedial  applications  to  these  nerves,  and 
from  the  phenomena  observed  to  follow  irritations  and  injuries  of 
other  branches  not  so  immediatel}^  connected  with  the  eye.  Some 
of  these  instances  it  will  be  proper  to  mention.  A  friend  of  the 
writer,  a  distinguished  surgeon  of  New  York  City,  was  inca})aci- 
tated  for  business  by  violent  neuralgia  of  the  face  ;  after  having 
suffered  some  time  with  it,  he  noticed  that  one  of  his  molar  teeth 
was  defective,  and  went   to  a   dentist  to  have  it  examined, — not 


NEURALGIA.  745 

supposing,  however,  that  it  had  any  connection  with  his  neui-algia, 
since  it  gave  him  no  pain.  Its  removal  was  advised.  The  operation 
was  scarcliely  over  before  the  doctor  experienced  complete  relief 
from  his  excessive  pain.  '  I  felt,'  he  said,  'as  if  I  could  have 
shouted  for  joy.'  A  lady,  a  short  time  since,  applied  to  me  to 
extract  a  tooth  for  her  little  daughter,  which,  she  said,  had  been 
causing  her  excruciating  pain  day  and  night;  but,  on  examination, 
I  could  discover  no  defect,  and  prescribed  some  anodyne  remedy, 
which  gave  only  temporary  relief.  A  dentist  was  called  in,  who 
also  declined  extracting  a  sound  tooth,  but  on  a  second  visit,  and  a 
closer  examination,  detected  an  unsound  tooth  at  some  distance 
from  the  offending  one,  and  extracted  it.  The  pain  instantly  ceased, 
and  did  not  recur.  Mackenzie  relates  a  remarkable  case  in  point. 
A  man  had  violent  neuralgia  of  the  eye,  soon  succeeded  by  amau- 
rosis, and  continuing,  notwithstanding  various  treatment,  from  the 
autumn  of  1825  until  the  beginning  of  1827.  At  this  time  M. 
Galenzowski,  to  whom  he  applied,  'found  vision  of  the  left  eye  lost 
and  the  pupil  dilated.  He  extracted  a  decayed  tooth  from  the  left 
upper  jaw,  and,  to  his  astonishment  and  that  of  the  patient,  found, 
attached  to  its  root,  a  splinter  of  wood,  supposed  to  have  been  origi- 
nally attached  to  a  toothpick  of  wood.  Nine  days  after,  the  patient 
had  entifely  regained  his  sight.'  Mackenzie  relates  another  equally 
remarkable  case,  occurring  in  the  practice  of  Dr.  Van  Zandt,  of  St. 
Louis,  '  of  a  young  man  affected  with  complete  amaurosis,  excited 
by  the  persistence  of  two  deciduous  teeth.  As  soon  as  they  were 
extracted,  the  patient  looked  up  as  if  terrified,  audi  found  his  vision 
restored.'  'Morgagni,  Notta,  Deval,  Tavignot,  and  others,'  says 
M.  Echeverria,  'have  known  amaurosis  to  be  caused  by  neuralgia, 
and  to  disappear  as  soon  as  the  neuralgia  was  cured.'  (The  italics 
in  the  above  references  are  my  own. — L.)  Such  cases  as  these 
might  be  multiplied,  but  it  is  scarcely  necessary."        *        *        * 

"  There  are  several  features  in  the  rather  remarkable  history  of 
Antoinette  H.  which  require  some  notice  before  concluding  this 
article.  It  was  objected  by  a  very  distinguished  oculist,  to  whom 
the  case  "  [one  in  which  part  of  a  gun  cap  was  accidentally  driven 
into  the  pericranium  of  the  left  side  of  the  forehead,  producing 
amaurotic  and  other  disturbance]  "  was  related,  soon  after  its  occur- 
rence, that,  the  wound  being  on  the  left  side,  the  amaurotic  symp- 
toms should  have  affected  the  left  eye,  and  not  the  right.  But  this 
is  not  more  remarkable  than  that  disease  in  one  tooth  should  occa- 
sion a  violent  toothache  in  another  perfectly  sound  ;  or  that  irritation 


746  ORAL  DISEASES  AND   SUBGERY. 

of  the  nerves  of  the  stomach  by  acidity  should  induce  violent  neu- 
ralgia of  the  supraorbital  nerve  ;  or  that  an  irritating  application  to 
the  mucous  surface  of  the  eyelid  should  determine  also  an  immediate 
irritation  of  the  Schneiderian  membrane,  succeeded  by  violent  sneez- 
ing ;  or  that  simply  touching  the  membrana  tympani  with  a  probe 
should  sometimes  give  immediate  relief  to  a  toothache." — {Dental 
Cosmos.) 

"  Facial  Paralysis. — Dr.  Coale  reports  the  following  case.  The 
patient  was  a  healthy,  well-regulated  girl,  aged  eighteen,  who  at  first 
noticed  that  her  face  was  somewhat  stiff,  and  in  twenty-four  hours 
completely  paralyzed  on  the  left  side.  There  was  great  distortion 
on  laughing  or  talking,  a  staring  left  eye,  and  tenderness  of  the 
whole  left  side  of  the  face.  The  tongue  was  not  at  all  affected,  the 
disease  being  confined  to  the  portio  dura.  No  cause  could  be  found 
for  it,  unless  it  were  that  she  had  defective  teeth  in  each  jaw,  as 
much,  however,  on  one  side  of  the  mouth  as  the  other.  The  treat- 
ment consisted  of  leeches  to  the  place  of  exit  of  the  nerves,  strychnia, 
etc.,  but  with  no  benefit.  After  the  lapse  of  three  weeks,  she  was 
advised  to  have  her  carious  teeth  removed,  and  thirteen  were  accord- 
ingly extracted.  This  was  followed  by  manifest  improvement  in 
the  course  of  five  days.  Electro-galvanism  was  then  gently  em- 
ployed, and  the  patient  recovered. 

"  Dr.  T3ier  said  that  several  years  ago  he  had  under  his  care  a 
lady  with  severe  sciatica,  for  which  all  the  usual  remedies  had  been 
tried  in  vain.  Finding  that  she  had  several  decayed  teeth,  he  ex- 
tracted four  or  five  of  them,  with  benefit.  The  remainder  were  sub- 
sequently drawn,  after  which  the  patient  had  no  more  pain. 

"In  1853,  a  boy,  aged  nineteen,  was  brought  to  the  New  Hamp- 
shire Asylum  in  a  state  of  mania.  Dr.  Tyler  ascertained  that  he 
had  had  a  tooth  extracted  some  time  previous,  and  that  one  of  the 
fangs  had  broken  ofiF,  and  remained  in  the  jaw.  Suppuration  took 
place,  the  pus  discharging  outwardly,  and  the  boy  was  suddenly 
attacked  with  mania.  The  fang  was  removed.  The  fistulous  opening 
closed,  and  the  patient  quickly  recovered  from  his  mania. 

"  In  another  case  of  mania,  the  patient  being  a  young  lady,  several 
decayed  teeth  were  removed.  The  patient  remained  to  some  extent 
under  the  influence  of  the  ether,  which  was  given  at  the  operation, 
for  twenty-four  hours.     After  that  she  was  cured  of  the  mania." 

Insanity  sometimes  caused  by  Diseased  Teeth. — James  Trudean, 
M.D.,  of  Paris,  says,  "  M.  Esquirol  told  me  that  he  had  cured  a 
young  lady,  who  was  insane,  of  her  mania  by  the  extraction  of  her 


NEURALGIA.  747 

second  molar  tooth,  which  was  preventing  the  growth  of  a  wisdom- 
tooth." 

Ex)ilepsy  from  Diseased  Teeth. — Dr.  Rush  ("  Medical  Inquiries 
and  Observations")  says,  "Some  time  in  the  year  1801,  I  was  con- 
sulted by  the  father  of  a  young  gentleman  in  Baltimore,  who  had 
been  afflicted  with  epilepsy.  I  inquired  into  the  state  of  his  teeth, 
and  was  informed  that  several  of  them  in  his  upper  jaw  were  much 
decayed.  I  directed  them  to  be  extracted,  and  advised  him  after- 
ward to  lose  a  few  ounces  of  blood  at  any  time  that  he  felt  the 
premonitory  symptoms  of  a  recurrence  of  his  fits.  He  followed  my 
advice,  in  consequence  of  which  I  had  lately  the  pleasure  of  hearing, 
from  his  brother,  that  he  was  perfectly  cured." 

Paralysis  from  Dental  Irritation. — The  American  Journal  of 
Dental  Science,  New  Series,  vol.  i.  p.  504,  quotes  from  the  London 
Lancet,  as  reported   by  J.  L.  Levison,  of  Brighton,   the  following 

case:  "Miss ,  a  young  lady,  was  brpught  in  a  carriage  to  my 

residence  to  have  her  mouth  examined.  On  being  removed,  she 
was  supported  by  a  lady  on  one  side  and  a  man-servant  on  the  other, 
and  her  entire  muscular  system  seemed  paralyzed.  Her  legs  trailed 
on  the  ground  like  useless  appendages  ;  her  arms,  when  raised,  fell 
powerless  immediately,  when  unsupported ;  and  even  the  muscles 
of  the  tongue  were  paralyzed,  and  in  her  efforts  to  speak,  this  im- 
portant organ  remained  in  a  quiescent  state.  On  examining  the 
mouth,  I  perceived  a  dens  sapientiae  of  the  lower  jaw  very  carious, 
and  deeply  imbedded  in  the  temporal  muscle,  just  below  the  ridge 
of  the  coronoid  process,  in  which  locality  there  was  extensive  in- 
flammation. I  suggested  the  removal  of  the  tooth  ;  and,  though  I 
had  anticipated  some  advantage  from  the  opei'ation,  the  actual  result 
astonished  me.  She  instantly  obtained  the  free  use  of  her  tongue, 
which  she  immediately  used  to  communicate  an  important  fact,  viz., 
that  ever  since  the  tooth  I  had  extracted  had  been  making  its  way 
through  the  gum  she  could  date  the  gradual  loss  of  power  over  her 
limbs,  etc.  I  saw  her  about  a  month  afterward ;  she  could  then  use 
her  hand  and  arm, — she  was  writing  a  letter  !  Since  then  I  have 
not  heard  what  progress  she  has  made." 

Sir  Astley  Cooper,  in  speaking  of  the  effects  of  slight  irritation, 
says,  "  M.  Toulmin,  of  Hackney,  attended  a  lady  on  account  of  her 
suffering  unusually  from  a  diseased  tooth,  and  she  appeared  to  be 
afflicted  with  hemiplegia,  M.  Toulmin  extracted  the  tooth,  and  in  a 
short  time  the  paralytic  affection  entirely  subsided." 

Catalepsy  from  Toothache. — The  Dental  Recorder,  vol.  viii.  No. 


748  ORAL  DISEASES   AND  SURGERY. 

1,  p.  197  (1854),  quotes  from  Tlie  Stethoscope,  as  reported  by  Dr. 
Hilton,  the  following-  ease  : 

"  Willis,  a  plowboj  (October  last),  was  complaining  of  toothache 
early  in  the  morning;  half  an  hour  after  commencing  work  was 
observed  lying  a  short  distance  from  the  plow,  apparently  dead.  He 
was  carried  to  the  house,  nearly  a  mile,  and  the  doctor  (five  miles 
distant)  sent  for.  In  the  belief  that  the  effect  might  be  produced 
through  the  dental  nerve,  the  tooth  was  extracted,  when  the  boy 
immediately  got  up  and  expressed  himself  as  well  as  ever;  and  has 
continued  well  since.  He  had  been  an  unusually  healthy  boy,  and 
had  never  had  a  physician  to  see  him  before." 

The  following  interesting  and,  in  a  neuralgic  aspect,  suggestive 
cases  were  collated  by  Dr.  Abraham  Robertson,  of  Virginia,  and 
published  in  the  Dental  Goamos  : 

"  Chorea  is  sometimes  caused  by  Dental  Irritation. — The  Ameri- 
can Journal  of  Dental  Science,  vol.  vi..  New  Series,  p.  146,  quotes 
from  the  Denial  News  Letter  the  following 

"Case. — Dr.  Billard  sa\'s,  after  an  examination  of  the  case,  which 
was  one  of  what  is  commonly  called  St.  Vitus's  dance,  that  he  found 
several  stumps  in  both  jaws,  the  gums  entirely  covering  some  of 
them,  and  on  pressure  of  the  same  it  caused  her  great  pain,  and 
pus  exuded  on  the  slightest  pressure.  *****!  proceeded 
to  give  ether,  and  it  took  a  double  quantity  to  make  her  insensible 
to  pain.  I  then  took  out  eight  stumps  and  some  small  pieces  of 
dead  alveoli,  which  had  caused  a  continuous  irritation  of  the  parts. 
Since  that  time,  the  author  states,  the  paroxysms  grew  less  frequent, 
and  now  the  patient,  Miss  L.,  enjoys  her  usual  health." 

"  Erysipelas  from  a  Diseased  Tooth;  Death  of  Patient. — The 
following  case  was  reported  by  Dr.  Thompson,  of  the  'Seanjan's 
'Retreat'  (N.  Y.),  and  furnished  to  the  New  York  3Iedical  Gazette, 
in  which  it  was  published,  vol.  iii.  p.  263  (1852),  by  Dr.  Sayer,  of 
that  city. 

"  Case. — Charles  Lunt,  aged  thirty,  Swede,  arrived  June  28  from 
Havre.  Admitted  into  hospital,  at  the  date  just  mentioned,  for  an 
inflammatory  tumefaction  of  left  cheek  and  parotid  gland  of  three 
days'  standing,  as  patient  stated,  from  toothache,  with  which  he  had 
been  annoyed  for  several  days  previous  to  the  swollen  face.  Patient 
otherwise  healthy,  and  of  a  stout,  robust  appearance. 

"On  admission,  the  tooth  of  which  he  complained  was  extracted; 
there  discharged,  in  cutting  about  the  tooth,  a  considerable  quantity 
of  fetid   pus.     After  extraction  of  the  tooth,  a  powder  of  calomel 


NEURALGIA.  749 

and  rhubarb  was  given,  and  an  emollient  poultice  applied  to  the  face. 
The  latter  was  continued,  and  antiphlogistic  remedies  pursued,  but 
without  much  relief  to  the  pain  or  reduction  of  the  swelling, — when, 
after  several  days,  the  inflammation  assumed  an  erysipelatous  char- 
acter. The  affected  parts  were  now  painted  wtth  a  strong  solution 
of  nitrate  of  silver,  evaporating  lotions  applied,  and  the  remedies 
indicated  by  the  constitutional  symptoms  administered  internally. 
This  treatment  persisted  in,  the  inflammation,  in  a  short  time,  greatly 
subsided,  and  these  promised  hopes  of  a  speedy  recovery.  Suddenly, 
however,  the  erysipelas  commenced  to  spread,  and  the  accompany- 
ing symptoms  to  increase  in  violence,  until  the  palpebra  of  the  (left) 
eye  and  parts  adjacent  became  involved.  As  the  disease  advanced, 
pus  was  formed  in  several  places,  which  was  evacuated.  The  con- 
junctiva, partaking  of  the  contiguous  inflammation,  became  swollen 
and  oedematous.  The  other  tissues  of  the  eye  also  soon  became 
involved,  and  now  occurred  delirium  and  other  symptoms  indicative 
of  the  extension  of  the  inflammation  to  the  brain.  This  being  ap- 
prehended, a  vigorous  revulsive  antiphlogistic  course  of  treatment 
was  adopted,  but  without  much  relief  to  the  patient.  The  symp- 
toms just  alluded  to  continuing,  and  gradually  increasing  in  violence, 
the  disease  on  the  fourth  day  of  their  occurrence  proved  fatal." 

"Vicarious  Menstruation  from  Decayed  Teeth.  —  Dr.  Rush, 
'Medical  Observations  and  Inquiries,'  says,  in  the  second  number 
of  a  work  entitled  '  Bibliotheque  Germanique  Medico-Chirurgicale,' 
published  in  Paris  by  Dr.  Bluver  and  Dr.  Delaroche,  there  is  an 
account  published  by  Dr.  Siebold  of  a  young  woman  who  had  been 
affected  for  several  months  with  great  inflammation,  pain,  and  ulcers 
in  her  right  upper  and  lower  jaws,  at  the  usual  time  of  the  appear- 
ance of  the  catamenia,  which  at  that  period  were  always  deficient 
in  quantity.  Upon  inspecting  the  seats  of  these  morbid  affections 
the  doctor  discovered  several  of  the  molars  in  both  jaws  to  be  de- 
cayed. He  directed  them  to  be  drawn,  in  consequence  of  which 
the  woman  was  relieved  of  the  monthly  disease  in  her  mouth,  and 
afterward  had  a  regular  discharge  of  her  catamenia." 

"  Dr.  S.  P.  Hullihen  reported  the  following 

"  Case. — A  young  lady,  about  seventeen  years  of  age,  applied 
with  a  fungous  growth  in  each  of  the  second  molars  of  the  lower 
jaw,  which  bad  assumed  rather  a  novel  character.  She  stated  that 
the  fungi  had  made  their  appearance  in  both  teeth  at  the  same  time, 
about  four  years  before,  and  that  for  the  last  two  years  she  had 
been  much  troubled  with  a  bleeding  from  them,  which  took  place 


750  ORAL  DISEASES  AND  SURGEBY. 

regularly  once  a  roonth,  and  continued  several  days.  She  being 
very  anxious  to  have  the  teeth  saved,  I  destroyed,  to  all  appear- 
ance, the  morbid  growth,  and  plugged  the  teeth.  In  a  few  days 
they  became  sore  and  painful.  The  plugs  were  removed,  and  a  slight 
bleeding  commence,  which  continued  three  or  four  days,  and  then 
the  tumors  entirely  disappeared.  I  was,  therefore,  induced  to  plug 
them  again  ;  but  in  about  three  weeks  the  teeth  became  sore :  the 
plugs  were  removed,  and  a  bleeding  ensued  as  before.  I  now  sus- 
pected it  to  be  a  vicarious  menstruation,  and  mentioned  the  case  to 
the  family  physician.  At  his  request  I  plugged  them  again,  and  the 
result  was  precisely  as  before.  The  teeth  were  then  removed,  and 
the  patient  was  put  under  a  course  of  treatment  by  her  physician, 
which  effected  a  cure. 

"As  somewhat  allied  to  this,  I  will  here  venture  the  opinion, 
although  I  have  no  case  in  mind  by  which  to  illustrate  the  fact,  that 
other  uterine  diseases  are  often  greatly  aggravated,  if  not  induced, 
by  this  san)e  cause.  And,  improbable  as  it  may  at  first  seem, 
especially  do  I  believe  this  to  be  true  in  relation  to  one  of  the  most 
common  afflictions — a  very  severe  affliction,  too — of  the  females  of 
our  country,  prolapsus  of  the  uterus. 

"  This  much,  at  least,  is  certain  :  general  debility,  however  in- 
duced, is  a  most  common  cause  of  this  complaint ;  and  I  have  often 
observed  that  when  it  is  not  complicated  with  other  diseases,  as  in- 
flammation, ulceration,  etc.,  it  may  readily  be  cured,  often  by  topical 
applications  only,  or  by  topical  applications  in  conjunction  with 
tonics  and  healthful  exercise  in  the  open  air,  and  sometimes  by  the 
tonics  and  exercise  without  any  topical  treatment,  or  perhaps  by 
Dr.  Meigs's  cure  alone,  of  'six  miles'  walk  a  day,  commencing  with 
small  doses,  and  increasing  according  to  ability  ;'  but  if  from  any 
cause  the  general  health  afterward  suffers,  and  debility  ensues,  a 
recurrence  of  the  prolapsus  will  also  be  likely  to  ensue.  And  since 
diseased  teeth,  by  the  nervous  irritation  they  produce,  by  the  de- 
rangement they  cause  in  the  digestive  and  respiratory  organs,  are 
a  most  common  and  potent  cause  of  such  debility,  they  must  neces- 
sarily be  the  cause,  indirectly  at  least,  of  this  kind  of  suffering." 

Epilepsy  connected  with  Denial  Irritation. — "  I.  D.,  aged  thirteen, 
has  had  epilepsy  eighteen  months.  Had  no  fits  in  infancy,  no  ner- 
vous affection  up  to  the  period  of  present  illness.  Family  history 
good.  First  attack  occurred  after  eating  some  crab-fish  for  supper. 
It  was  long  and  violent.  The  second  occurred  after  two  months' 
interval ;  cause  of  this  not  known.     The  third  occurred  in  fourteen 


NEURALGIA.  751 

days,  and  they  have  recurred  at  varying  intervals, — from  one  week 
to  three  weeks.  They  always  occur  during  the  night.  He  screams 
sometimes,  and  not  unfrequently  bites  his  tongue.  Latterly  his 
mother  has  noticed  that  some  days  he  rubs  his  left  cheek,  complain- 
ing of  face-ache,  after  which  the  fit  follows.  He  is  a  healthy-looking 
boy;  tolerabh^  well-fleshed,  although  the  muscles  feel  somewhat 
flabby.  He  is  intelligent,  and  does  not  appear  to  have  suffered  in 
apprehension  or  memory;  no  headache  or  vertigo.  Organic  func- 
tions tolerably  well  performed  ;  no  inter-paroxysmal  phenomena. 
On  examining  the  mouth,  there  is  to  be  seen  a  molar  tooth  consider- 
ably decayed,  with  a  swollen  gum  around  it,  and  partly  growing 
over  into  the  cavity ;  it  is  not  very  tender  to  touch,  and  the  exami- 
nation does  not  give  rise  to  toothache.  On  questioning,  I  find  the 
sensation  which  the  boy  experiences  before  a  fit  does  not  seem  to  be 
one  of  pain,  but  rather  of  an  indefinite  uneasiness.  He  always  has 
a  fit  the  night  on  which  this  uneasiness  comes  on.  Has  never  felt 
it  during  the  day;  it  is  always  about  seven  to  eight  o'clock.  I 
desired  the  mother  to  have  the  tooth  extracted,  and  ordered  a  simple 
saline,  with  a  quarter  of  a  grain  of  belladonna,  to  be  taken  twice 
daily.  This  was  in  June.  The  tooth  was  extracted  next  day.  I 
saw  this  boy  once  a  fortnight  from  that  time  for  four  months,  but 
he  has  had  no  recurrence  of  the  fit. 

"  In  this  case  I  believe  an  unfelt  aura  commenced  about  the  gum 
surrounding  the  tooth,  and  w^as  not  recognized  till  some  degree  of 
inflammation  arose,  and  thus  a  modification  of  pain  became  asso- 
ciated with  the  aura,  and  directed  attention  to  it.  I  have,  at  the 
present  moment,  another  and  very  similar  case  to  this.  The  extrac- 
tion of  the  tooth  has  not  yet  been  performed,  so  that  I  cannot  give 
you  the  result.  When  epilepsy  occurs  in  children,  I  always  examine 
the  mouth,  with  the  twofold  view  of  observing  the  vault  as  to  height, 
narrowness,  etc.,  inasmuch  as  no  observation  about  the  cranial  de- 
velopment can  be  complete  without  such  examination,  and  of  ascer- 
taining whether  any  cause  of  eccentric  irritation  may  spring  from 
decayed  or  crowded  teeth.  I  would  observe  here  that,  later,  the 
dentes  sapientiae  often  become  a  source  of  considerable  irritation, 
and,  therefore,  of  complication,  at  least  in  the  epilepsy  of  young- 
persons." — (Dr.  J.  S.  Kamskill,  Medical  Times  and  Gazette.) 

Many  very  interesting  and  instructive  cases  of  neuralgia  may  be 
found  by  the  reader  reported  by  Dr.  S.  Weir  Mitchell  in  his  work 
on  "Injuries  of  the  Nerves,"  which  can  only  be  studied  with  the 
result  of  adding  indorsement  to  the  inference  of  the  local  origin  of 
this  complaint. 


752  ORAL  DISEASES  AND  SURGERY. 

Among  the  reports  of  the  clinical  services  of  the  author  will  be 
found  two  by  Dr.  De  Forrest  Willard,  where  in  one  instance  an  old 
man  who  had  suffered  with  neuralgia  of  the  head  for  sixty  years, 
and  who  many  years  back  had  endured  section  of  the  facial  nerve, 
was  cured  by  the  removal  of  an  imbedded  tooth-fang  conjoined 
with  the  extraction  of  an  abraded  inferior  incisor.  In  the  second 
case,  a  German  aged  about  fifty,  a  neuralgia  which  had  been  under 
every  variety  of  treatment  for  several  years  was  clearly  demon- 
strated to  depend  on  calcification  of  dental  pulps. 

The  use  of  the  constant  galvanic  current  is  credited  with  the  cure 
of  many  cases  of  neuralgia, — the  Weiss  battery,  used  with  from 
ten  to  fifteen  cells,  being,  in  this  direction,  highly  commended  by  Drs. 
Anstie,  Buzzard,  Joseph  Stead,  and  others.  The  Stohrer  battery, 
made  by  the  Galvano-Faradic  Company,  of  New  York,  is  highly 
spoken  of  by  Dr.  S.  Weir  Mitchell. 

Batteries  made  in  Philadelphia  are  quite  equal  to  any  others, 
either  of  foreign  or  domestic  make.  In  sixteen  cases  of  treatment 
by  battery  application,  Dr  Buzzard  reports  "ten  followed  by  very 
great  and  well-marked  relief,  two  by  moderate  relief,  and  four  by 
very  slight  relief." 

"  Dr.  Anstie  refers  to  two  cases, — one  of  severe  neuralgia  in  the 
right  cervico-brachialis,  in  a  married  woman  aged  forty-eight;  the 
other  of  a  double  cervico-occipital  neuralgia,  in  an  unniarried 
needle-woman  aged  thirty.  In  the  former  case  a  cure  was  effected; 
in  the  latter,  not.  The  constant  current  was  employed,  with  the 
strength  of  ten  cells,  afterward  increased  to  fifteen  ;  the  positive 
pole  in  the  first  case  being  applied  alternately  on  the  various  foci 
of  pain,  the  negative  pole  being  applied  by  the  right  side  of  the 
three  lower  cervical  vertebrae.  The  pain  was  at  once  diminished, 
and  ceased  altogether  at  the  end  of  thirteen  days;  and  a  secondary 
anaesthesia  of  the  skin,  with  secondary  paralysis  of  the  deltoid  and 
trapezius,  was  removed  at  the  end  of  twenty-four  days'  treatment. 
The  cure  was  found  persistent  six  weeks  later.  Dr.  Anstie  re- 
marks that  the  effect  of  the  constant  current  in  neuralgia  is  re- 
markable, but  that  there  are  as  yet  some  unexplained  anomalies 
in  its  action.  In  the  large  majority  of  cases  it  acts  as  a  palliative 
most  strikingly.  In  a  not  inconsiderable  number  of  cases  it  ap- 
pears to  cure  the  disease  absolutely;  in  a  few  examples  it  fails 
to  produce  any  good  eflfeots.  As  a  general  rule,  it  is  far  less 
eflective  in  the  neuralgias  of  old  persons  with  degenerated  tissues 
than  in  younger  subjects ;  but  occasionally  even  a  young  person, 


NEURALGIA.  753 

like  the  second  of  his  cases,  fails  to  derive  benefit  from  it." — {Lancet 
and  Neio  Remedies.) 

A  writer  in  The  American  Practitioner  recommends  dropping 
into  the  meatus  auditorius  from  four  to  ten  drops  of  the  following 
mixture,  remarking  it  to  be  "  very  rare,  with  the  use  of  this  liquid, 
that  relief  is  not  obtained  in  a  few  minutes,  and  the  patient  asleep 
in  half  an  hour,  whatever  may  have  been  the  severity  of  the  pains, 
and  that  without  having  been  in  the  least  danger.  Absorption 
takes  place  almost  as  rapidly  as  from  a  denuded  surface,  and  it  is, 
therefore,  unnecessary  to  blister  the  patient  when  we  wish  to  use 
narcotics,  since  they  act  almost  as  rapidly  by  the  auditory  passage. 

R. — Extracti  opii, 

Extracti  belladonnge, 
Extracti  stramonii,  aa  pars  j  ; 
Aquae  pruni  Yirginiani,  partes  xij. 

"  If  it  should  happen,"  says  this  writer,  "  that  at  the  end  of  eight 
or  ten  minutes  the  pain  does  not  yield  to  the  remedy  (which  some- 
times happens  when  the  quantity  used  has  been  too  small,  or  when 
we  have  to  treat  a  neuralgia  which  has  already  required  the  use  of 
narcotics  in  any  way),  it  is  necessary  to  use  a  second  dose,  at  least 
equal  to  the  first,  but  in  the  opposite  case,  in  order  to  obtain 
promptly  that  relief  which  is  only  too  frequently  momentary,  of 
facial  neuralgias  of  long  standing." 

Alluding  to  the  extemporaneous  character  of  the  preparation,  it 
is  suggested  that  it  may  be  preserved,  if  care  is  taken  to  keep  it  cool, 
by  pouring  on  its  surface  from  two  to  four  drops  of  sweet  almond 
oil. 

Among  the  recipes  found  in  Dr.  Napheys's  "Modern  Therapeu- 
tics," which  have  been  selected  from  the  most  eminent  practitioners, 
are  the  following,  which  may  not  be  without  service  to  many  readers  : 

Wm.  Aitken,  M.D.,  Edinburgh  : 

When  the  neuralgia  is  superficial,  compresses  steeped  in  the  fol- 
lowing solution : 

B. — Atropiae  sulphatis,  gr.  v  ; 
Aquae  destillatis,  f^iij. 

Renew  the  compresses  several  times  in  twenty-four  hours,  con- 
tinue them  for  at  least  an  hour  each  time,  and  cover  them  with  oil- 
skin to  prevent  evaporation. 

48 


754  ORAL  DISEASES  AND  SURGEBY. 

Brown-Sequard  : 

R. — Extract!  belladonnae,  gv.  \  ; 

Extract!  stramonii,  gr.  \  ; 

Extract!  cannabis  Indicae,  gr.  ^ ; 

Extract!  acon!t!,  gr.  J  ; 

Extract!  byoscyam!,  gr.  | ; 

Extract!  con!!,  gr.  j  ; 

Pulver!s  glycyrrhizae,  q.  s. 
For  one  p!ll.     To  be  used  w!th  care,  and  not  over  four  a  day. 

Dr.  Da  Costa  : 

R. — Aconitise,  gr.  ij  ; 
Yeratriae,  gr.  xv  ; 
Glyceriuae,  f5ij  ; 
Cerati  ad!p!s,  '^v].     M. 
To  be  rubbed  over  the  painful  part,  care  being  taken  to  see  that 
there  is  no  abrasion  of  the  skin. 

Dr.  Wm.  Hammond: 

R. — Extracti  belladonnae,  gr.  v. 
Divide  into  twenty  pills.     One  three  times  a  day. 

Liniment  of  Guy's  Hospital : 

R. — Liquoris  plumb!  subacctatis, 

Tincturae  opii, 

Mellis,  aa  5'j  ; 

Confectionis  rosae,  §j. 
Fiat  linimentum. 

London  Hospital  : 

R. — Tincturae  aconiti, 

Liniment!  saponis,  aa  f^j. 
To  be  used  as  an  anodyne  liniment. 

A  liniment  recommended  by  Dr.  Napheys  as  an  elegant  sedative 
is  as  follows  : 

R. — Atropiae  sulphatis,  gr.  viij  ; 
Morphiae  sulphatis,  gr.  xvj  ; 
Aconitiae,  gr.  ij  ; 
Acid!  sulphuric!  diluti,  "Iv  ; 
Alcoholis,  f^ss ; 
Ole!  olivse,  q.  s.  ad  f^iv.     M. 


I 


NEURALGIA.  755 

Or,  if  a  stimulant  effect  is  also  desired  : 
R. — Cbloroformi,  f^ss  ; 

Spiritus  terebinthinae,  f^j  ; 
Campboris,  5j  I 
Olei  lavandulffi,  ^^Ixx; 
Olei  olivae,  q.  s.  ad  f^vj.     M. 
The  first  four  ingredients  should  be  mixed  before  adding  the  oil, 
and  the  liniment  should  be  well  shaken  before  it  is  applied. 

Dr.  Felix  von  Niemeyer,  University  of  Tiibingen  : 
R. — Extracti  hyoscyarai, 
Zinci  oxidi,  aa  9ij.     M. 
Divide  into  eleven  pills.     Begin  with  one  pill  morning  and  even- 
ing, and  increase  to  twenty  or  thirty  of  them  daily.     These,  known 
as  the  Meglin  pills,  have  a  good  reputation  in  Germany. 

Edward  Wakes,  M.D.,  London  : 

R. — Potass®  bicarbonatis,  5ss  ; 

Extracti  ergotae  fluidi,  f3j  ; 

Infusi  ergotae,  f^vj.     M. 
Two  tablespoonfuls  every  four  hours  in  tic-douloureux. 

One  of  the  most  intractable  neuralgiae  of  the  head  ever  met  with 
in  the  practice  of  the  author,  yielded  to  compression  of  the  facial 
arteries. 

Methodical  rubbing  of  a  neuralgic  seat  is  recommended  by  Dr.  S. 
Weir  Mitchell. 

In  a  case,  noted  by  this  author,  of  contusion  of  the  ulnar  nerve 
subject  to  intense  neuralgia,  the  nerve  being  hardened  and  enlarged, 
tender,  and  enduring  no  application  of  electricity,  the  pain  was  re- 
lieved by  hypodermic  injections ;  but  after  using  many  remedies, 
and  at  last  the  actual  cautery  over  the  nerve-trunk  without  altering 
its  size  or  tenderness,  slow  and  careful  manipulation  was  tried  to 
test  if  it  could  be  enabled  to  bear  pressure.  After  a  course  of  gentle 
friction,  lasting  half  an  hour,  the  object  was  attained,  three  sittings 
enabling  the  parts  to  be  rubbed  and  even  kneaded  quite  roughly. 

Concerning  the  odonto-neuralgiae,  the  reader  is  referred  to  the 
chapter  on  Odontalgia. 


CHAPTER    XXXYI  I, 

THE   TONGUE   AND   ITS   DISEASES. 

Of  medical  diseases  the  tongue  has  long  been  esteemed  a  reliable 
sentinel :  hence,  many  and  varied  must  be  its  expressions  of  functional 
derangements  in  the  system  at  large.  To  term  such  expressions 
disease,  however,  could  not  by  any  means  be  proper,  the  sympathetic 
relationship  being  evident  to  the  most  superficial  observer.  In  the 
foot-note  the  reader  will  find  such  medical  aspect  of  the  subject  con- 
sidered with  all  fullness.* 

*  "  In  drawing  inferences  from  the  condition  of  this  organ,  it  is  important 
to  know  whether  the  appearances  it  may  present  are  the  result  of  local  disease 
in  the  mouth,  or  of  the  sympathies  which  connect  it  with  other  parts  of  the 
system.  In  general,  there  is  little  difficulty  in  coming  to  a  correct  conclusion 
upon  this  point:  it  is  only  necessary  that  the  ^attention  should  be  directed 
toward  it.  This  organ  seems  to  have  been  designed  as  an  index,  to  the  eye  as 
well  as  to  the  ear,  of  the  state  of  the  system,  so  numerous  and  diversified  are 
the  morbid  aff"ections  which  modify  its  healthy  appearance.  It  not  only  par- 
ticipates in  all  general  derangements  of  the  whole  system,  serving  as  one  of 
the  surest  guides  to  a  correct  judgment  in  relation  to  the  degree,  progress, 
and  precise  stage  of  the  disease,  but  especially  also  sympathizes  with  the 
different  parts  of  the  digestive  tube,  at  one  extremity  of  which  it  is  placed. 

"  The  bulk  of  the  tongue  may  be  increased  or  diminished.  Its  enlargement, 
when  not  so  considerable  as  to  be  very  obvious,  may  often  be  known  by  the 
appearance  of  indentations  on  its  sides,  made  by  the  pressure  of  the  teeth. 
This  is  occasionally  one  of  the  first  signs  of  the  mercurial  influence.  Its 
contraction,  when  not  the  mere  e9"ect  of  dryness,  is  usually  the  result  of  a 
diminished  supply  of  blood,  and  indicates  either  a  general  deficiency  of  the 
circulating  fluid,  or  great  feebleness  of  the  heart's  action.  Like  every  other 
part  naturally  moist,  it  shrinks  by  drying  ;  and,  under  such  circumstances, 
no  general  inference  can  be  deduced  from  its  mere  loss  of  volume. 

"  Its  color  is  often  greatly  and  significantly  modified.  Morbid  floridness  of 
the  tongue  is  the  consequence  either  of  the  condition  of  the  blood,  or  of  its 
greater  abundance  in  the  organ.  In  the  former  case  an  unduly  arterialized 
state  of  the  mass  of  the  blood  is  indicated  ;  in  the  latter,  either  over-excite- 
ment of  the  circulation  generally,  or  phlogosis  of  the  stomach.  Redness  of 
the  tongue,  not  the  result  of  local  causes  exclusively,  has  been  supposed  by 
some  pathologists  to  be  an  almost  certain  sign  of  gastric  inflammation  or 
irritation.  But  this  is  far  from  being  the  case.  It  is  often  seen  when  no 
(756) 


THE   TONGUE  AND   ITS  DISEASES.  757 

Of  organic  or  surgical  diseases  the  tongue  seems  to  have  its  full 
share.     These  diseases  are  of  a  twofold  relation  :  local,  as  reference 

evidence  of  gastritis  is  presented,  either  by  the  symptoms  or  upon  dissection, 
and  is  not  unfrequcntly  absent  when  that  disease  exists.  Serious  practical 
injury  may  result  from  this  error.  The  red  tongue  can  be  considered  as 
having  special  reference  to  the  stomach  only  when  other  symptoms  point  in 
the  same  direction,  and  even  then  is  by  no  means  a  certain  sign.  A  livid  or 
pur-ple  color  of  the  tongue  is  usually  dependent  upon  an  insufficient  aeration 
of  the  blood,  and  is  a  valuable  sign  in  connection  with  the  same  color  of  the 
lips.  Not  unfrequently  the  tongue  is  morbidly  joaie;  and  this  state  is  a  sign 
of  defici(mcy  of  the  blood  in  general,  or  of  its  red  corpuscles  in  particular,  or 
of  great  prostration  of  the  circulating  forces. 

"  Its  condition  as  to  dryness  and  moiature  is  often  highly  significant.  But 
caution  is  necessary  not  to  mistake  dryness  from  temporary  and  unimportant 
causes,  for  that  which  results  from  general  disease.  In  persons  who  sleep 
habitually  with  their  mouths  open,  the  tongue  is  apt  to  be  dry  in  the  morning  ; 
and  the  same  cause  often  produces  the  same  etfect  in  sickness.  On  visiting  a 
patient  we  find  the  tongue  unexpectedly  dry,  and  begin  to  feel  some  appre- 
hension, until  we  learn  that  the  patient  has  been  breathing  for  some  time 
through  the  mouth  alone.  A  stoppage  of  the  nostrils  often  gives  rise  to  this 
phenomenon.  In  all  doubtful  cases  it  is  only  necessarj'  to  request  the  patient 
to  close  his  mouth  and  then  move  the  tongue  about  so  as  to  moisten  it.  If 
he  succeed  satisfactorily,  we  may  conclude  that  the  dryness  was  accidental, 
and  of  no  account.  Another  caution  is  requisite:  to  take  care,  namely,  that 
a  really  dry  tongue  should  not  be  mistaken  for  a  moist  one,  in  consequence 
of  the  patient  having  recently  taken  a  liquid  into  his  mouth.  Dryness  may- 
exist  in  different  degrees,  from  mere  clamminess  to  perfect  aridity.  It  de- 
pends on  a  deficiency  of  saliva,  or  of  mucus,  or  both,  and  indicates  a  general 
tendency  to  diminished  secretion.  It  not  unfrequently  occurs,  as  a  sympa- 
thetic affection,  in  ulcerative  inflammation  of  the  small  intestine.  It  affords 
sometimes  the  most  important  therapeutical  indications. 

"  The  temperature  of  the  tongue  serves  as  a  guide  to  that  of  the  body  gen- 
erally. When  cold,  it  evinces,  for  the  most  part,  great  prostration  of  the 
powers  of  life.  It  proves  that  the  process  of  calorification  is  failing  at  the 
very  fountain  ;  for  the  breath  must  be  cool  before  the  tongue  can  become  so 
in  any  considerable  degree.  This  coldness  of  the  tongue  has  been  frequently 
noticed  in  severe  cases  of  epidemic  cholera.  But  we  must  take  care  not  to 
confound  coolness  from  local  causes,  as  from  ice  in  the  mouth,  or  from  the 
patient  having  slept  long  with  the  mouth  open  in  a  cold  atmosphere,  with 
that  proceeding  from  the  state  of  the  system.  Heat  of  the  tongue,  except 
when  arising  from  inflammation  of  the  organ,  may  be  considered  as  a  sign  of 
a  general  elevation  of  temperature. 

"  But  the  condition  usually  denominated  a  furred  tongue  is,  perhaps,  the 
most  valuable  diagnostic  symptom  aff"orded  by  that  very  important  little 
member.  In  this  state  the  tongue  is  covered  with  a  morbid  coating,  which 
adheres  so  firmly  that  it  cannot  be  removed  without  removing  a  portion  of 


758  ORAL  DISEASES  AND  SURGERY. 

is  had  to  some  direct  cause  demanding  only  local  attention  ;  indirect, 
as  constitutional  ofiFense  is  the  agent  against  which  a  treatment  is 
to  be  directed. 

the  surface  along  with  it.  Occasionally  deposits  take  place  from  the  saliva 
and  the  mucus  of  the  mouth;  but  these  are  easily  removable,  and  must  be 
distinguished  from  the  genuine  fur.  The  latter  proceeds  from  a  secretory 
process  of  the  tongue  itself,  and  seems  to  be  incorporated  with  the  superficial 
layer  of  epithelium.  It  is  almost  always  confined  to  the  upper  surface,  where 
the  structure  of  the  membrane  is  papillary.  Though  very  generally  a  sign 
of  disease,  it  is  not  always  so.  Some  persons  have  a  furred  tongue  habitually, 
more  especially  upon  rising  in  the  morning  ;  and,  though  in  the  greater 
number  of  these  there  is  probably  some  chronic  disorder  of  digestion,  yet  in 
others  the  health  appears  to  be  perfect. 

"  A  furred  tongue  almost  always  accompanies  fever,  and  is  one  of  the  most 
decided  characteristics  of  that  affection.  Indeed,  when  considerable  in  degree, 
and  not  dependent  upon  stomatitis  of  any  kind,  it  may  very  generally  be  re- 
garded as  a  febrile  symptom.  When  the  fur  is  white,  thickish,  tolerably  uni- 
form, and  accompanied  with  moisture,  it  usually  indicates  an  open,  active 
state  of  fever,  in  which,  though  the  obvious  symptoms  may  possibly  be 
violent,  there  is  not  apt  to  be  any  lurking  mischief,  nor  any  malignant  tend- 
ency. When  short,  very  adhesive,  and  rather  scanty,  permitting  the  redness 
of  the  tongue  to  appear  through  it,  and  attended  with  some  disposition  to 
dryness,  it  is  often  a  sign  of  a  protracted  and  obstinate  form  of  fever,  which 
is  apt  to  assume  a  low,  nervous,  or  typhoid  form.  A  yellowish  hue  of  the  fur 
is  usually  indicative  of  bilious  disorder,  being  produced  either  by  the  vomit- 
ing of  bile,  or,  what  is  probably  much  more  frequent,  by  direct  secretion  from 
the  tongue,  consequent  upon  deficient  secretion  by  the  liver,  or  an  excessive 
production  of  bilious  matter  in  the  blood.  Not  unfrequently  this  color  of 
the  tongue  is  accompanied  with  a  bitter  taste.  It  is  common  in  miasmatic 
fevers  and  hepatic  diseases.  A  brown  or  black  tongue  is  usually  indicative  of 
a  low  state  of  the  system  and  an  impaired  condition  of  the  blood.  It  is  owing 
to  the  secretion  of  a  dark  matter,  apparently  identical  with  that  which  collects 
about  the  teeth  and  lips  in  typhous  fevers,  and  probably  consisting  of  blood 
modified  in  its  passage  out  of  the  vessels.  The  same  action  would  seem  to 
take  place  in  the  tongue  as  that  which,  in  the  stomach  and  bowels,  occasions 
the  black  discharges  so  common  in  malignant  fevers.  It  may  depend  on  an 
enfeebled  state  of  the  secreting  tissue,  or  a  diseased  state  of  the  blood,  or  on 
both  united.  Yery  frequently  this  darkness  of  the  tongue  supervenes  upon  a 
previously  white  coating,  and  indicates  a  deteriorated  state  of  the  vital  forces 
and  probably  of  the  blood.  •  The  caution  should  be  observed,  not  to  ccmfound 
this  discoloration  with  that  which  may  proceed  from  accidental  causes,  as 
from  the  chewing  of  liquorice,  tobacco,  burnt  coffee-grains,  etc.  In  many 
instances,  the  white  fur  of  the  tongue  is  modified  by  red  points,  which  are  the 
tops  of  the  swollen  and  projecting  papillae.  This  appearance  is  not  uncommon 
in  eruptive  febrile  diseases,  especially  scarlet  fever  and  measles.  When  con- 
sequent upon  a  dyspeptic  state  of  the  stomach,  the  fur  is  most  copious  in  the 


THE   TONGUE  AND  ITS  DISEASES.  759 

Of  local  injuries,  reference  may  be  made  to  ulcers  caused  by  jagged 
and   projecting  teeth-roots,  to  cuts  and   contusions  from  falls  and 

morning  before  breakfast.  In  some  persons,  emptiness  of  the  stomach  is  said 
always  to  induce  this  state  of  the  tongue. 

"The  manner  in  which  a  furred  tongue  becomes  clean  affords  valuable 
indications.  When  the  fur  slowly  recedes  from  the  tip  and  edges,  thinning 
gradually  as  it  retires,  it  intimates  a  favorable  convalescence.  A  portion  of 
fur  often  lingers  near  the  root  of  the  tongue,  long  after  the  disease  has  given 
way.  In  another  mode  of  cleaning,  the  fur  loosens  and  separates  in  flakes, 
often  beginning  at  the  middle  or  near  the  root,  sometimes  in  large  patches, 
or  over  almost  the  whole  tongue  at  once,  leaving  a  smooth,  red,  glossy  sur- 
face, as  though  the  papillary  structure  had  been  lost.  In  such  cases,  if  acute, 
and  if  the  tongue  remains  moist,  convalescence  almost  always  takes  place, 
though  usually  tedious,  and  sometimes  very  lingering.  In  threatening  fevers, 
it  is  VQVj  desirable  to  witness  this  phenomenon  ;  and,  as  it  is  often  preceded 
by  a  feeling  of  soreness  in  the  fauces,  this  may  be  considered,  when  it  occurs 
'in  such  cases,  as  an  auspicious  circumstance.  Much  stress  was  laid  upon  this 
as  a  prognostic  symptom  by  the  late  Dr.  Joseph  Parrish,  of  Philadelphia. 
Sometimes  the  fur  recurs  once  and  again,  before  it  ultimately  disappears;  and 
weeks  and  even  months  are  occasionally  consumed  in  the  struggling  and 
apparently  uncertain  advance  of  the  system  toward  health.  In  less  favor- 
able cases,  the  tongue,  after  having  commenced  the  process  of  cleaning,  as 
just  described,  or  even  after  completing  it,  instead  of  continuing  moist,  be- 
comes as  dry  as  a  chip,  with  an  aggravation  of  all  the  symptoms,  and  no 
little  increase  of  danger.  The  indication  is  still  more  unfavorable  when,  in 
addition  to  its  dryness,  the  surface  becomes  gashed,  chapped,  or  fissured,  or 
exhibits  a  rough,  scaly  appearance. 

"  This  smooth,  red,  and  glossy  state  of  the  tongue,  sometimes  with  moisture 
and  sometimes  with  dryness,  is  not  uncommon  in  chronic  diseases,  in  which 
it  is  generally  a  bad  sign,  and  is  supposed  to  indicate  serious  organic  derange- 
ment of  the  alimentary  mucous  membrane.  A  still  worse  condition,  how- 
ever, is  an  aphthous  state  of  the  tongue,  which  is  apt  to  come  on  in  the 
advanced  stages  of  chronic  diseases,  and  is  generally  to  be  received,  under 
these  circumstances,  as  a  fatal  sign,  though  of  itself,  and  occurring  in  ordi- 
nary health,  it  is  in  no  degree  alarming. 

"A  loss  or  depravation  of  taste  is  not  uncommon,  and  is  generally  of  little 
consequence,  depending  upon  a  mere  derangement  of  the  surface  which  re- 
ceives the  gustatory  impressions.  But  when  of  a  paralytic  nature  it  is  much 
more  serious,  as  it  generally  indicates  disease  within  the  encephalon. 

"  The  only  other  point  requiring  consideration  refers  io  i\ie  movements  oi 
the  tongue.  When,  in  acute  febrile  diseases,  these  are  not  under  the  control 
of  the  patient,  when  upon  being  requested  to  protrude  his  tongue  he  is  un- 
able to  do  so,  or  when  the  organ  trembles  much  in  the  attempt,  the  symptom 
is  exceedingly  unfavorable,  indicating  either  great  prostration,  or  dangerous 
cerebral  disease.  Of  similar  unfavorable  prognostication,  under  the  same 
circumstances,  is  the  occurrence  of  a  diflicult  and  hesitating  utterance,  like 


760  ORAL  DISEASES  AND  SURGERY. 

blows,  to  bites  inflicted  under  various  circumstances  by  the  teeth, 
to  papular  hypertrophies,  to  epithelial  indurations  and  ulcerations, 
to  stings  from  insects  in  fruit-season,  to  burns,  scalds,  the  incautious 
or  accidental  mastication  of  acrid  or  irritating  substances,  to  glossitis, 
from  the  excessive  use  of  tobacco,  from  operations  performed  on 
neighboring  parts,  from  mustard  administered  in  strength  in  neces- 
sity for  sudden  emesis,  etc. 

Of  associate  or  constitutional  diseases,  the  most  prominent  are  the 
syphilitic  and  mercurial  impressions  appearing  in  the  form  of  acute 
or  chronic  inflammations,  indurations,  fissures,  ulcers,  and  cysts. 
Malignant  manifestations,  particularly  the  expressive  scirrhus,  have 
here  also  not  unfrequently  a  first  expression. 

With  the  almost  exhaustive  observations  of  the  quotation  from  Pro- 
fessor Wood,  given  in  the  foot-note,  is  to  be  associated  the  fact  that  in 
some  nervous,  irritable  persons  the  tongue  is  found  habitually  furred, 
yet  without  any  symptoms  of  gastric  or  other  derangement.  Some 
persons  get  furred  tongue  the  moment  their  stomachs  are  empty ; 
others  have  their  tongues  coated  always  after  a  meal  and  while 
digestion  is  going  on,  the  coating  passing  away  as  the  function 
ceases.  Mental  and  moral  emotions  have  a  decided  influence. 
Dr.  Wright,  in  one  of  his  clinical  lectures,  mentions  the  following 
striking  illustration  : 

"In  calling  upon  a  certain  patient,"  says  this  gentleman,  "the 
first  thing  I  did  was  to  look  at  his  tongue.  I  found  it,  as  usual, 
very  pale,  flabby,  and  moist,  but  without  any  coating.  After  having 
made  other  necessary  inquiries,  I  was  informed  by  my  patient  that 
his  heart,  which  had  long  been  disturbed  by  mental  emotions,  had  on 
the  previous  evening  beaten  with  unusual  violence  and  irregularity. 
On  my  asking  if  he  could  account  for  it,  he  told  me  that  he  had  just 
then  received  the  distressing  intelligence  that  an  uncle,  from  whom 
he  expected  a  competency,  had  not  left  him  a  shilling.  This  pitiable 
tale,  told  with  much  earnestness  and  visible  feeling,  occupied  little 
more  than  twenty  minutes.  At  the  end  of  that  time  I  again  looked 
at  his  tongue,  and  found  it  coated  with  a  thick,  white  fur." 

The  most  frequent  disease  of  the  tongue  met  with  is  perhaps 
syphilis.  Syphilitic  ulcers,  the  most  common  of  the  manifestations, 
appear  on  any  part  of  the  organ,  but  are  most  common  on  the  sides 

stammering.  The  inclination  of  the  tongue  toward  one  side  when  pro- 
truded usually  indicates  palsy,  and  is  one  of  the  common  attendants  upon 
hemiplegia." — Wood. 


THE   TONGUE  AND   ITS  DISEASES.  761 

and  under  surface.  Such  ulcers  are  almost  invariably  accom- 
panied by  associations  of  their  origin,  —  psoriasis  on  the  body, 
nodes,  falling  of  the  hair,  lymphatic  induration  of  the  posterior  cer- 
vical ganglia.  A  syphilitic  ulcer  on  the  tongue  has  the  appearance 
of  chancre,  hard  or  soft;  we  meet  with  them  where  the  ulceration 
is  quite  deep  and  the  edges  are  heavily  indurated.  '  Again,  where 
there  is  neither  excavation  nor  induration,  we  nevertheless  know, 
from  the  associations,  and  from  the  peculiar  characteristic  appearance 
of  the  base,  that  they  are  venereal. 

A  second  form  of  syphilitic  disease  of  the  tongue  is  observed  in 
the  induration  and  hypertrophy  of  circumscribed  patches  of  mucous 
membrane.  The  induration  in  these  cases  is  so  markedly  localized 
that,  if  it  were  not  for  their  varying  locations, — being  always,  how- 
ever, on  the  dorsum, — one  might  readily  believe  them  to  be  enlarged 
eircumvallate  papillae  ;  the  patches  are  quite  as  large  as  a  dime  piece, 
are  elevated,  and  are  as  isolated  as  a  fungiform  wart.  The  author 
has  seen  two  such  patches  on  the  dorsum  of  a  tongue,  and  at  the 
same  time  a  large  ulcer  on  its  under  surface. 

Cracks  and  fissures  are  other  syphilitic  indications  met  with  on 
the  tongue.  It  may  happen  in  some  instances  that  these  fissures  are 
so  deep  as  to  seem  to  divide  the  organ  into  a  number  of  parts ;  they 
always,  so  far  as  the  author  has  observed,  run  lengthwise.  These 
fissures  are  at  times  unbearably  sore,  denying  the  patient  comfort 
either  in  eating  or  in  rest. 

Indurations  of  the  raucous  membrane  of  the  sides  of  the  tongue 
from  this  cause  are  occasionally  observed,  or  it  maybe  that  a  general 
thickening  exists,  or,  indeed,  that  the  whole  organ  is  indurated.  In 
this  latter  condition  the  disease  has  sometimes  been  mistaken  for 
cancer  ;  but  such  an  error  could  arise  only  from  a  failure  to  observe 
the  associations  of  the  case.* 

"  Syphiloma  {Gummata  Syphilitica)  of  the  Tongue.  Dr.  Neumann,  of  Vienna 
[Allgemehie  Wiener  Medizinische  Zeitung,  and  Half-Yearly  Abstract). — The 
dorsum  of  the  tongue,  as  is  well  known,  is  frequently  at  its  centre  or  lateral 
portions,  more  i-arely  at  the  root  of  the  organ,  the  seat  of  infiltrations, — the 
so-called  syphilitic  gummatous  tumors,  the  size,  superficial  aspect,  and  pro- 
gress of  which  undergo  many  variations.  These  tumors,  which  are  of  firm 
consistency,  are  seated  partly  under  the  mucous  membrane,  partly  in  the 
muscular  tissue  of  the  tongue,  and  are  developed  from  small  infiltrations  of 
the  size  of  a  pea  to  prominent  nodules  as  large  as  a  bean  or  hazelnut,  or  even 
larger.  The  growth  sometimes  extends  laterally,  so  as  to  form  level  patches: 
in  cases  of  this  kind  a  greater  part  of  the  tongue,  especially  its  edges,  feels 
thickened,  infiltrated,  and  hard  as  cartilage.     In  this  aflfection  the  mucous 


762  ORAL  DISEASES  AND   SURGERY. 

Sometimes  the  dorsum  presents  red  patches,  the  result,  evidently, 
of  a  loss  of  the  epithelial  covering.  These  patches  are  perfectly 
smooth,  not  ulcerated,  but  are  painfully  sensitive  to  hot  or  cold 
impressions ;  this  condition  will  be  met  with  where  the  dorsum 
seems  literally  skinned.  By  those  familiar  with  the  diagnostic 
description  of  the  tubercular  ulcer  as  insisted  on  by  M.  Tielert, 
it  will  be  seen  that  with  such  a  condition  his  premises  become  to  a 
marked  degree  confused. 

To  Prof  Sigmund  we  are  indebted  for  the  knowledge  of  the  fact 
that  the  raw  ulcerations  on  the  sides  of  the  tongue  called  syphilitic 
psoriasis  are  very  contagious,  a  diseased  child  poisoning  the  nurse, 
and  the  diseased  nurse  poisoning  the  child  by  chewing  its  food  first 
in  her  own  mouth. 


menibrane  covering  the  growth  is  either  smooth  or  covered  by  numerous 
papillarj'  growths,  which  occupy  a  large  portion  of  the  tongue  in  the  form  of 
broad-based  watery  formations,  or  the  surface  of  the  dorsum  may  be  trav- 
ersed by  shallow  furrows,  or  by  deep  fissures  crossing  in  various  directions, — 
rhagades  ;  or,  again,  if  the  mucous  membrane  be  irritated  by  the  sharp  edge 
of  a  decayed  tooth,  it  may  present  superficial  patches  of  gangrenous  tissue. 

"  The  whole  volume  of  the  tongue  is  increased  to  a  considerable  extent. 
Finally,  the  disease  may  proceed  by  softening  of  the  nodules  to  a  more  or 
less  extensive  and  deep  loss  of  substance,  in  consequence  of  which  the  tongue 
on  the  affected  side  presents  large  cavities,  which,  when  the  loss  of  substance 
has  aflPected  the  root  of  the  tongue,  exert  a  considerable  influence  upon  the 
consonance  of  the  speech.  The  movements  of  the  tongue,  also,  as  in  speak- 
ing, masticating,  and  swallowing,  cause  much  pain.  These  new  formations, 
consisting  partly  of  granulation  tissue  and  partly  of  connective  tissue, — 
which  tissue,  in  its  further  development,  becomes  either  soft  and  jelly-like,  or 
is  converted  into  adipose  tissue,  and  forms  dry  yellow  lumps, — were  described 
by  Eobin  and  E.  Wagner  as  syphiloma.  They  present  granular  cell  contents, 
and  their  cells  and  nuclei  lie  in  peculiar  hollow  spaces — alveolar  formation. 

"In  cases  of  this  kind  one  has  to  distinguish  the  infiltration  of  sj'philis 
from  that  of  cancer.  Hardness,  rapid  growth,  painfulness,  and  an  uneven 
surface,  are,  indeed,  symptoms  which  speak  more  for  cancer  than  for  syphilis  ; 
the  existence,  however,  of  a  sharply-defined  loss  of  substance,  and  the  pres- 
ence on  the  dorsum  of  the  tongue  of  warty  or  condylomatous  growths,  are 
indicative  of  gummatous  deposit.  In  cancerous  growths  of  the  size  of  syphi- 
litic gummata,  the  submaxillary  glands  would  certainl}-  be  enlarged.  In 
doubtful  cases  the  diagnosis  might  be  determined  by  means  of  the  microscope. 
In  some  cases  the  distinction  may  be  indicated  by  the  course  taken  by  the 
disease.  In  syphilitic  gummata  the  breaking  down  of  the  tumor  commences 
deeply,  and  proceeds  to  the  surface ;  in  cancer  the  opposite  takes  place,  loss  of 
substance  commences  superficially,  and  gradually  extends  to  the  centre  of  the 
growth." 


THE   TONGUE  AND   ITS  DISEASES.  763 

The  treatment  of  syphilis  in  the  tongue  has,  with  one  special  ex- 
ception, the  twofold  sig-niBcation  of  constitutional  and  local, — the 
exception  being  that  of  chancre.  It  has  without  doubt  occurred  that 
a  man  has  gotten  a  chancre  upon  his  tongue.  Mercury,  in  some  of 
its  various  forms,  seems  to  be  looked  upon  by  most  practitioners  as 
having  in  this  direction  something  specific  in  its  nature;  without 
doubt,  however,  it  is  a  greatly-abused  medicine,  and  should  be  used 
with  more  caution  and  judgment  than  generally  characterize  its 
exhibition. 

Where  ulcers  or  other  manifestations  upon  the  tongue  are  second- 
ary in  their  signification,  and  mercury  has  not  been  used  upon  the 
case,  it  is  marvelous  how  at  times,  under  its  influence,  such  mani- 
festations can  be  made  to  disappear.  How  this  medicine  is  to  be 
used  is  perhaps  best  left  to  be  directed  by  the  apparent  requirements 
of  individual  cases.  Of  one  thing,  however,  we  may  be  sure :  its 
best  effects  are  not  to  be  obtained  by  salivating  the  patient.  Mercury 
in  the  form  of  the  bichloride  is  a  favorite  preparation  ;  it  may  be 
given  in  doses  of  the  tenth  to  the  twentieth  of  a  grain  dissolved  in 
water  or  the  fluid  extract  of  sarsaparilla,  three  times  a  day.  The 
hydrargyrum  cum  creta,  combined  with  Dover's  powder,  is  a  combi- 
nation which  may  be  used  with  benefit  where  dryness  and  other  lack 
of  function  are  found  in  the  skin.  Impression  by  inunction  is  another 
mode  of  exhibiting  the  medicine.  A  lump  of  mercurial  ointment, 
the  size  of  a  large  pea,  may  be  rubbed  into  the  inner  face  of  the 
thighs  night  and  morning.  Calomel  in  quarter-grain  doses,  com- 
bined with  small  quantities  of  sugar  to  render  it  palatable,  may  be 
given  every  two  or  three  hours,  until  the  patient  remarks  the  cop- 
pery taste.  Blue  pill,  in  five-grain  doses,  answers  very  well  if  there 
be  no  hepatic  disturbance,  as  manifested  by  gastric  derangement 
and  sick-headache. 

Of  the  various  mercurial  preparations,  the  preference  will  be 
found  to  reside  with  the  bichloride  :  in  this  form  the  impression  of 
the  medicine  is  gradually  secured.  If  necessary,  it  may  be  given 
continuously  for  a  month. 

Combined  with  the  mercurials,  it  is  a  common  experience  that 
tonics  are  generally  found  indicated, — a  something  to  counteract  the 
degenerative  tendency  which  appears  to  reside  in  every  dose  of  a 
mercurial  administered.  Iron,  quinine,  gentian,  and  the  red  bark 
are  excellent  preparations.  A  prescription  which  will  be  found  to 
be  a  very  good  one  is  as  follows: 


764  ORAL  DISEASES  AND   SURGERY. 

R. — Hydrargyri  chloridi  corrosivi,  gr.  iv  ; 

Tincturae  cinchonae  eompositse,  §vj.     M. 
Sig. — A  teaspooiiful  three  times  a  day. 

A  second,  admirable  in  cases  associated  with  nervous  disturbance, 
is  the  combination  with  the  mercurial  of  the  pyrophosphate  of  iron  : 

R. — Hydrargyri  chloridi  corrosivi,  gr.  vj  ; 

Syrupi  ferri  pyrophosphatis,  5^j-     M. 
Sig. — A  teaspoonful  three  times  a  day. 

In  syphilitic  disease  of  the  tongue,  tertiary  in  its  type,  mercury 
will  seldom  be  found  admissible.  The  system  is  broken  down  :  the 
process  of  cure  must  be  one  of  regenerative  repair.  These  are  the 
patients  for  the  sea-shore  and  the  hill-side.  You  will  not  get  them 
well  if  you  cannot  build  them  up. 

Conjoined  with  the  tonic  medication  of  these  cases,  very  ex- 
perienced authorities  commend,  for  its  alterative  influence,  the  use  of 
the  iodide  of  potassium.  Where  it  is  thought  desirable  to  use  this 
medicine,  ten  grains  as  a  dose  for  the  adult  may  be  given  three  times 
a  day.  It  is  most  conveniently  exhibited  in  water,  or,  if  taste  is 
consulted,  in  the  fluid  extract  of  sarsaparilla. 

Tertiary  symptoms,  as  M.  Ricord  observes,  do  not  inevitably  occur 
in  the  course  of  syphilis,  but  they  are  very  likely  to  do  so  if  the 
treatment  of  the  primarv  and  secondary  symptoms  be  not  conducted 
with  the  greatest  care.  As  soon  as  the  tertiary  period  has  set 
in,  mercury  must  be  abandoned,  and  iodide  of  potassium  given. 
Nay,  further,  as  mercury  taken  in  time  may  prevent  or  retard  sec- 
ondary symptoms,  and  so  may  be  regarded  as  a  prophylactic  against 
them,  so  may  iodide  of  potassium  be  regarded  as  a  prophylactic 
against  tertiary  symptoms ;  and  therefore  M.  Ricord,  from  the 
premises  of  his  great  experience,  teaches  "  that  to  render  the  treat- 
ment of  secondary  syphilis  complete  and  rational,  it  should  always 
be  followed  by  the  exhibition  of  iodide  of  potassium.  This  substance 
is,  however,  not  only  useless  when  employed  against  secondary 
symptoms  and  those  of  transition,  but  very  often  hurtful ;  yet,  when 
secondaries  have  been  of  long  standing,  it  may  produce  beneficial 
effects  ;  it  is  also  useful  as  an  adjuvant  of  mercury  in  those  atfectioqB 
which  in  some  degree  lie  between  the  secondary  and  strictly  tertiary 
manifestations;  and,  finally,  it  is  indispensable  for  combating  the 
symptoms  of  a  decided  tertiary  nature.  In  order  to  become  well 
acquainted  with  the  proper  manner  of  administering  the  iodide  of 


THE   TONGUE  AND   ITS  DISEASES.  765 

potassium,  we  should  take  the  trouble  of  studying  its  effects,  inde- 
pendently of  its  curative  action.  First  let  us  see  how  it  acts  on  the 
skin.  It  may  produce  on  the  cutaneous  surface  diverse  psydracious 
and  acnoid  eruptions.  The  pustules  are  generally  surrounded  by  a 
vividly  red  areola,  and  the  usual  seat  of  these  eruptions  is  below  the 
umbilical  region,  as  the  nates,  thighs,  etc.,  whereas  the  common  acne 
(not  to  mention  its  other  characters)  is  mostly  situated  in  the  upper 
half  of  the  body.  To  these  peculiarities,  it  may  be  added  that  the 
pustules  will  fall  in  immediately  the  administration  of  the  iodide  is 
interrupted.  Exanthemata,  impetigo,  and  lichen  are  very  apt  to  be 
produced  by  the  use  of  this  salt;  and  what  you  ought  especially  to 
keep  in  mind  is,  that  ecchymosis  and  purpura  in  the  inferior  extrem- 
ities are  sometimes  caused  by  the  action  of  the  iodide  of  potassium. 
The  effects  of  the  latter  on  mucous  membranes  should  also  be  care- 
fully observed.  It  may  cause  inflammation  of  the  conjunctiva;  the 
submucous  cellular  tissue  lying  under  gets  infiltrated  and  puffed  up  ; 
the  eyelids  turn  red  and  oedematous,  and,  when  the  inflammation 
and  effusion  are  not  arrested,  the  internal  parts  of  the  eye  become 
involved  in  the  affection,  and  photophobia  is  the  result  of  this  state 
of  things.  The  normal  mucous  secretion  is  always  a  little  increased, 
but  it  does  not  take  the  muco-purulent  character,  as  in  the  case  of 
catarrhal  ophthalmia.  Coryza,  of  a  more  or  less  severe  nature,  often 
exists  at  the  same  time  ;  it  is  preceded  and  accompanied  by  headache, 
and  a  pretty  abundant  mucous  secretion  ;  but  this  coryza  never 
reaches  the  suppurative  state ;  it  never  produces  more  than  a  catar- 
rho-serous  flux.  These  affections  never  give  rise  to  any  fever,  and 
they  disappear  as  soon  as  the  iodide  is  given  up.  This  coryza  is  an 
accident  which  we  should  not  overlook ;  for  it  is  of  importance  to 
avoid  it  when  we  have  to  treat  a  tertiary  affection  of  the  nasal  fossae. 
As  for  the  effect  of  the  iodide  on  the  intestinal  canal,  I  have  to  state 
that  persons  enjoying  good  health  can  bear  very  large  doses  of  it ;  I 
have  given  as  much  as  fifteen  drachms  a  day.  M.  Fuche  has  often 
given  ten  drachms  per  diem,  after  commencing  with  six  ;  and  it  has 
been  noticed  that  it  improves  the  appetite  of  the  persons  who  use  it. 
With  some  patients  a  certain  pleurodynic  sensation,  corresponding 
to  the  cardiac  extremity  of  the  stomach,  is  felt  after  its  ingestion  ;  but 
it  never  causes  vomiting.  The  submucous  cellular  tissue  of  the 
stomach  may,  by  the  use  of  tliis  iodide,  undergo  the  same  modifica- 
tions which  we  have  noticed  the  conjunctiva  to  be  subject  to :  a  sort 
of  hyper-secretion  and  intestinal  ptyalism  takes  place,  and  much  of 
the  fluid  which  ought  to  have  been  secreted  by  the  skin  is  rejected 


766  ORAL  DISEASES  AND   SURGERY. 

by  the  mouth.  This  liquid  has  a  slight  taste  of  iodine  ;  it  is  not 
fetid  in  the  least;  the  gums  are  not  swollen,  and  there  is  no  fetor  in 
the  breath,  as  happens  in  mercurial  ptyalism.  The  same  effect  may 
be  produced  on  the  other  portions  of  the  intestinal  canal ;  tlie  patients 
are  then  seized  with  abundant  serous  diarrhoea.  The  iodine  is  elim- 
inated from  the  system  by  the  kidnej'S  ;  half  an  hour  after  the  inges. 
tion  of  it,  its  presence  may  be  ascertained  in  the  urine;  and  it  should 
be  remembered  that  the  presence  of  iodine  in  the  blood  increases  the 
renal  secretion.  I  have  even  observed  a  case  of  polydipsia  which 
went  on  as  long  as  the  iodide  was  used,  but  disappeared  when  the 
latter  was  discontinued,  and  gradually  sprang  up  again  as  the  use 
of  the  salt  was  resumed. 

"  The  effects  of  the  iodide  of  potassium  on  the  circulation  are  of 
a  sedative  kind;  it  diminishes  the  number  of  arterial  pulsations, 
and  lowers  their  force,  but  they  may  regain  their  normal  standard 
if  the  remedy  act  beneficially  on  the  system ;  the  same  arterial  en- 
ergy may  also  reappear  when  the  iodide  causes  a  slight  phlegmasia. 
This  salt  is  somewhat  antiplastic ;  for  it  has  rather  a  tendency  to 
liquefy  the  blood,  and  may  even  produce  the  peculiar  hemorrhages 
of  purpura.  When  the  effect  of  the  iodide  on  the  nervous  system  is 
carefully  watched,  it  is  found  to  cause  a  certain  excitement  of  the 
nervous  centres,  followed  by  a  little  uncertainty  in  the  movements 
and  in  the  intelligence." 

A  combination  much  employed  by  Sir  Astley  Cooper,  in  cases 
where  the  iodide  of  potassium  seemed  not  to  favor  the  patient,  was 
the  liquor  arsenici  et  hydrargyri  hydriodatis, — Donovan's  solution. 

Concerning  the  local  treatment  of  the  venereal  affections  of  the 
tongue,  with  which,  in  a  work  like  this,  we  would  seem  to  have 
most  to  do,  little  is  to  be  added  outside  of  the  suggestions  offered 
on  previous  pages.  The  treatment  is  principally  to  be  constitutional 
in  character  :  direct  medication  is  perhaps  to  be  esteemed  simply  as 
palliative. 

As  a  local  application  of  a  common  signification,  lactuca  sativa 
five  ounces,  honey  one  ounce  and  a  half,  and  alum  one  drachm  and 
a  half,  is  a  favorite  with  Ricord.  Another  consists  of  a  decoction 
of  hemlock,  six  ounces  and  a  half,  to  bichloride  of  mercury,  three 
grains.  From  my  own  experience,  I  have  suggested  the  use  of  acids 
applied  to  the  ulcers  in  cases  where  the  dyscrasia  has  been  corrected 
or  nearly  so.  It  is  surprising  with  what  rapidity  a  syphilitic  ulcer 
will  occasionally  respond  to  almost  any  of  the  mineral  acids. 

In  a  bad  case  of  mucous  tubercles  I  once  treated,  I  got  my  patient 


THE   TONGUE  AND   ITS  DISEASES.  767 

well  by  daily  salt-baths  and  the  local  use  of  a  paint  composed  of 
sulphate  of  quinia  and  iron  ;  twenty-five  grains  of  the  former  to 
two  drachms  of  the  muriated  tincture  forming  the  combination. 
The  tubercles  were  painted  twice  a  day  for  two  months. 

Borax  is  a  soothing  application  ;  it  may  be  rubbed  with  water 
into  a  cream,  and  thus  be  applied  ad  libitum. 

A  species  of  local  specific,  to  be  used  on  the  part  and  rinsed  away 
after  a  few  moments,  is  composed  as  follows: 

R. — Aquse  destillatae,  5ixss  ; 
Ferri  perchloridi, 
Acidi  acetici, 

Acidi  h3^drochlorici,  aa  5j.     M. 
This  may  be  repeated  three  times  a  day. 

Fissures  and  fistulas  are  sometimes,  in  their  chronic  form,  cauter- 
ized, nitric  acid,  pure  or  dilute,  being  used  for  the  purpose.  In  a 
case  of  long-standing  fissure  of  the  tongue,  the  author  on  one  occasion 
cut  out  the  induration,  the  patient  making  a  rapid  recovery. 

Chloride  of  zinc,  twenty  grains  to  the  ounce  of  water,  will  be 
found  a  useful  application  in  chronic  syphilitic  conditions,  whether 
of  ulcer,  fistula,  or  fissure. 

"In  smokers  and  persons  addicted  to  strong  drinks  or  fed  on 
irritating  diet,  the  lips,  cheeks,  tongue,  and  especially  the  fauces,  as 
pointed  out  by  Dr.  Charles  Drysdale,  and  as  has  frequently  been 
observed  by  the  author,  become  the  seat  of  interminable  eruptions 
of  mucous  syphilitic  lesions,  just  as  in  the  external  genitalia  of 
women."  These  habits  are  not  to  be  indulged  in  by  persons  so 
afflicted. 

Mercurial  enlargement  and  induration  of  the  tongue  is  a  condition 
frequently  demanding  treatment.  One  of  the  first  effects  of  this 
medicine  is  often  seen  in  the  markings  made  upon  the  sides  of  this 
organ  by  an  otherwise  not  observed  swelling  which  has  crowded  it 
against  the  teeth.  -The  tongue  tumefied  by  the  impressions  of  calo- 
mel may  become  so  enlarged  as  to  fill  the  whole  mouth.  One  par- 
ticular case  I  recall,  where,  to  prevent  the  patient  from  being  smoth- 
ered, I  was  compelled  to  dnig  the  tongue  forward  over  the  lower 
jaw,  and  thus  fix  it  until  relief  could  be  otherwise  secured. 

Mercurial  ulceration  of  the  tongue  is  another  of  the  offenses  of 
this  medicine.  Such  ulcerations  are  in  appearance  indolent  and  yet 
irritable,  and  are  associated  with  similar  conditions  of  the  gums,  and 
with  salivation:  the  diagnosis  is  very  plainly  marked. 


768  ORAL  DISEASES  AND   SURGERY. 

The  rational  treatment  of  the  mercurial  conditions  refers  to  the 
correction  of  the  local  impressions,  together  with  elimination  from, 
and  support  applied  to,  the  system  at  large.  In  rapid  swellings  of 
the  tongue,  it  may  be  found  necessary  to  resort  to  the  use  of  leeches 
combined  with  most  marked  derivation.  In  the  case  above  referred 
to,  forty  common  leeches  were  applied  to  the  throat,  the  patient 
was  profusely  sweated,  and  these  applications  were  succeeded  by  a 
saline  cathartic. 

Such  treatment,  combined,  if  the  circulation  is  sthenic,  with  some 
arterial  depressant,  as  digitalis,  aconite,  or  veratrum,  will  commonly 
relieve  from  the  immediate  danger.  Unless,  however,  the  ptyalism 
has  been  acutely  excited,  and  the  subject  is  strong  and  vigorous, 
this  treatment  will  be  succeeded  by  great  lassitude  and  depression  ; 
but  such  depression  is  a  necessity,  and  has  perhaps  saved  the 
life. 

A  local  treatment  in  cases  of  this  kind  is  simply  palliative  and 
soothing.  The  lactuca  sativa  and  honey,  recommended  in  the  syphi- 
litic sore-mouth,  is  an  excellent  gargle.  Sage-tea,  combined  to  a 
full  saturation  with  chlorate  of  potassa,  is  another  agreeable  ap- 
plication. Common  table-tea  is  very  grateful  to  a  patient.  In 
combination  with  these,  or  any  similar  demulcent  gargle,  great  relief 
has  been  derived  from  the  free  exhibition,  internally,  of  the  bromide 
of  potassium. 

R. — Potassii  bromidi,  5ss  ; 

Aqu-ae,  o^i'j-     ^^■ 
Sig. — Tablespoonful  repeated  occasionally  as  the  patient  is  found 
nervous.     Twenty  grains,  as  here  directed,  may  be  prescribed  three 
times  a  day  at  the  least.     The  author  has  given  eighty  at  a  single 
dose. 

The  acute  conditions  of  a  mercurial  glossitis  combated,  the  prac- 
titioner may  find  it  desirable  to  attend  to  the  more  general  require- 
ments of  the  case.  The  system  is  to  be  protected  against  further 
impressions  of  the  agent,  while  at  the  same  tinle  it  will  generally 
be  found  that  a  present  support  is  demanded.  Chlorate  of  potassa, 
the  antagonist  of  the  mercurials,  has  now  obtained  in  this  direc- 
tion an  almost  universal  use:  it  may  be  administered  in  full  satu- 
ration, in  tablespoonful  doses,  three  or  four  times  a  day.  A  very 
good  way  to  prescribe  this  salt  is  to  order  one  ounce  placed  in  an 
eight-ounce  bottle,  which  is  to  be  kept  filled  with  water  until  all  is 
dissolved.  As  each  dose  is  taken,  the  patient  replaces  it  with  fresh 
water. 


THE   TONGUE  AND   ITS  DISEASES.  769 

In  the  treatment  of  the  mercurial  ulcer,  the  local  applications 
suggested  have  been  various.  Bismuth,  red  bark,  and  borax,  in 
equal  proportions,  act  sometimes  very  happily.  Chlorate  of  potassa, 
tannic  acid,  and  glycerine  form  another  excellent  combination.  Solu- 
tions of  sulphate  of  copper  or  zinc,  one  grain  to  the  ounce  of  water, 
are  cleansing  and  stimulating  applications.  Iron,  opium,  chalk- 
powder,  aromatic  powder,  are  all,  in  their  turn  and  place,  useful. 
If  phagedsena  intervene  or  threaten,  the  potassio-tartrate  of  iron,  as 
recommended  by  Ricord  in  the  similar  ulcers  of  syphilis,  is  not  to 
be  omitted:  it  may  be  used  in  the  strength  of  thirty  grains  to  the 
ounce.  It  should  also  be  administered  internally  in  doses  varying 
from  five  to  ten  grains  repeated  every  two  hours. 

Chronic  phagedsena,  which  in  some  degree  associates  itself  more 
or  less  frequently  with  mercurial  ulcers,  is  best  treated  by  the  poten- 
tial cauterants.  Of  these,  a  favorite  is  creasote:  this  is  to  be  applied 
with  care,  however,  as  it  may  provoke  secondary  inflammation. 
Carbolic  acid  is  a  useful  article,  and  will  sometimes  prove  very 
reliable.  Nitric  and  hydrochloric  acids  are  highly  recommended 
by  many  practitioners:  when  applied,  every  recess  of  the  sore  is  to 
be  burned,  and  this  should  be  repeated  daily  until  healthy  granula- 
tions are  provoked. 

SciRRHUs.  —  Of  the  third  form  of  constitutional  impressions, 
scirrhous  carcinoma  may  now  engage  our  consideration.  This 
scirrhus  of  the  tongue,  from  the  circumstances  of  its  association  and 
position,  is  to  be  deemed  a  necessarily  dangerous,  if  not  fatal,  disease. 
Scirrhus  in  other  parts  may  be  cured ;  that  is  to  say,  being  removed, 
it  may  not  reappear  in  the  part  of  removal, — although,  being  a  con- 
stitutional condition,  the  disease  is  seldom,  if  indeed  ever,  perma- 
nently destroyed.  That  scirrhous  carcinoma  is  not,  however,  at 
least  in  its  incipiency,  so  formidable  an  expression  as  the  encephaloid, 
seems  to  be  the  universal  impression :  there  is  a  fixedness,  an  appar- 
ent isolation  about  it,  which  always  invites  operation  ;  that  is  to  say, 
as  is  expressed  in  the  chapter  on  Tumors,  it  exhibits  the  existence 
of  an  antagonism  on  the  part  of  the  vital  force  which  invites  and 
promises  good  from  assistance. 

Situated  in  the  tongue,  such  isolation  is,  however,  unfortunately, 
not  so  marked  as  when  found  in  many  other  parts:  the  disease  ap- 
pears here  as  an  induration  rather  than  as  what  might  be  termed 
a  lump,  and  this  induration  has  not,  commonly,  a  definite  boundary; 
hence,  if  it  be  removed  by  operation,  one  is  at  a  loss  to  say  whether 
such  removal  has  been  complete. 

49 


770 


ORAL  DISEASES  AND  SURGERY. 


A  carcinomatous  scirrhus  is  to  be  distinguished  from  scirrhus  of 
local  signification, — first,  by  its  resistance  to  treatment;  and,  second, 
bv  the  peculiar  darting,  lancinating  pains  which,  sooner  or  later, 
always  appear  in  it;  these  pains  are  markedly  diagnostic.  Again,  a 
scirrhous  carcinoma  is  apt  to  have  a  hereditary  history :  a  generation 
may  have  escaped,  but  it  is  apt  to  be  discovered  somewhere  in  the 
family. 

Local  medication  to  a  carcinomatous  scirrhus  is  perhaps  worse 
than  useless.  If  it  is  not  widely  cut  away,  it  is  better,  a  hundred 
times,  to  let  it  alone.  Many  a  tumor  of  this  class  that  would  have 
remained  dormant  for  years  has  been  excited  to  the  most  destructive 
malignancy  by  over-officious  meddling  with  it.  If  a  practitioner  does 
not  know  the  character  of  a  tumefaction  upon  a  tongue,  he  cannot 
act  more  wisely  than  in  doing  notliing  at  all,  until,  at  least,  time  and 
continued  observation  have  made  the  diagnosis  plain  to  him. 

At  a  period  very  various  as  to  time,  a  scirrhous  carcinoma  ulcer- 
ates. If  the  tumor  has  attained  any  size,  fungous  granulations 
sprout  forth,  giving  that  expression  known  as  fungus  haematodes  ; 
if,  on  the  contrary,  the  tumor  ulcerates  while  small,  it  is  irregular, 
puckered,  everted  in  its  edges  or  elevated,  and  covered  with  abun- 
dant granulations :  the  discharge  may  be  thin  and  sanious,  or 
purulent,  the  latter  character  being,  however,  rare:  it  differs  from 
the  syphilitic  sore  in  its  grauulative  bottom. 

A  section  of  scirrhous  carcinoma  presents  a  stroma  dense,  abun- 
dant, and  closely  meshed.  A  fibrous  struc- 
ture is  always  more  or  less  marked,  par- 
ticularly in  its  occult  state,  such  structure 
assimilating  both  the  white  and  yellow 
tissues,  being  perhaps  really  these  tissues. 
A  diagnostic  sign  is  a  peculiar  creak  or 
cry  given  under  the  knife.  Another  is  a 
shrinkage  or  contraction  in  the  centre  of 
a  section.  Still  another  is  a  creamy  juice, 
which  may  often  be  scraped  from  it. 

In  looking  at  a  microscopic  slice  of 
scirrhous  carcinoma,  the  areolae  existing 
in  the  stroma  are  found  filled  with  gran- 
ules, nuclei,  and  nucleated  cells:  these 
cells  being  of  most  diversified  form  and 
common  to  no    tissue,    the   term    heteroclitic  is  justly  applied  to 


Fig.  242. 


W^^ 


A  microscopic  viewof  tlie  cancer- 
cells  filling  the  interstices  among 
tlie  bundles  of  the  fibro-cellular 
tissue  in  the  skin  of  the  breast. 
Magnified  about  two  hundred  times. 
(After  Paget.) 


THE   TONGUE  AND   ITS  DISEASES.  771 

them.     The  appearance  of  such  a  section  is  exhibited  in  the  engrav- 
ing, Fig.  242.* 


*"  It  is  well  known  that  whenever  a  special  predisposition  to  abnormal 
action  exists  in  the  vital  economy,  a  very  slight  thing  is  sufficient  to  act  as  an 
exciting  cause  of  disease.  This  is  especially  the  case  in  many  affections  of 
both  an  organic  and  dynamic  character,  examples  of  which  we  have  occa- 
sionally presented,  among  which  was  the  apparent  development  of  cancer 
from  the  irritation  produced  by  rough  or  decayed  teeth.  Additional  evidence 
upon  this  point  is  furnished  by  the  following  cases  from  the  clinical  report  on 
epithelial  cancer,  by  Mr.  Jonathan  Hutchinson,  in  the  Medical.  Times  and 
Gazette:  'George  P.,  aged  thirty-six,  a. dark,  sallow,  but  healthy-looking 
man,  was  admitted,  December  29,  1853,  into  St.  Bartholomew's  Hospital, 
under  the  care  of  Mr.  Stanley,  for  a  cancerous  ulcer  in  the  middle  of  the  right 
margin  of  the  tongue,  about  an  inch  in  length,  half  an  inch  in  width,  and 
half  a  line  to  a  line  in  depth.  The  base  was  irregular,  not  granular,  nor  dis- 
tinctly nodular  or  warty ;  it  was  clean  and  moderately  florid,  and  while  in 
the  hospital,  and  being  guarded  from  the  teeth  by  an  ivory  cover  for  them, 
it  became  level,  and  skinned  over  very  thinly,  yet  enough  to  prevent  its 
bleeding  when  lightly  rubbed.  The  borders  of  the  ulcer  were  upraised,  with 
a  somewhat  lobed  or  glandular  surface.  This  was  especially  the  case  with  the 
upper  border,  which,  occupying  a  portion  of  the  dorsum  of  the  tongue,  over- 
hung a  little  the  adjacent  mucous  membrane.  The  elevated  border  felt  firm, 
tense,  and  nearly  hard  ;  the  base  of  the  ulcer  was  equally  so,  and  these  char- 
acters were  evidently  derived  from  morbid  deposits  at  and  for  about  two  to 
three  lines  beyond  the  ulcerated  surface.  At  the  border  this  deposit  did  not 
involve  the  very  surface-layer  of  the  mucous  membrane,  which  was  tensely 
stretched  over  it,  but  discernible  with  its  small  vessels.  The  rest  of  the 
tongue  appeared  to  be  all  healthy.  One  lymph-gland  by  the  side  of  the  facial 
artery  was  slightly  enlarged,  firm,  but  not  hard.  The  teeth  by  the  side  of  the 
ulcer  were  not  rough,  but  neither  were  they  clean,  and,  as  already  said,  the 
ulcer  became  smoother  and  skinned  over  when  protected  from  them. 

"  '  He  said  that  nine  months  previously  his  tongue  had  become  sore  through 
the  "  fretting"  of  a  decayed  tooth  at  this  part.  He  allowed  the  tooth  to  re- 
main for  six  months,  the  sore  extending  all  the  time  until  it  had  reached  its 
present  dimensions.  At  length,  three  months  ago,  the  tooth  was  drawn  ;  the 
sore  remained,  and  he  was  not  aware  of  any  change  in  its  character.  It  was 
always  very  painful,  and  the  pain  extended  from  it  over  the  whole  cheek  and 
the  side  of  the  head  and  jaw.  Many  of  the  cervical  lymphatic  glands  under 
the  right  side  of  the  jaw  had  been  enlarged,  but  they  had  subsided  two  months 
previously;  and  the  one  by  the  facial  artery  had  only  in  the  last  week  been 
enlarged.  His  great-aunt  died  of  cancer  of  the  throat  (sufficiently  proved)  ; 
but  no  other  relative  was  known  to  have  had  cancer.  He  never  had  any 
syphilis  or  well-marked  struma.' 

"After  an  ineffectual  effort  to  remove  the  disease  by  constitutional  treat- 
ment with  iodide  of  potassium,  the  part  was  excised  :  the  troublesome  symp- 


772  ORAL  DISEASES  AND  SUBGERY. 

As  scirrhous  carcinoma  always  begins  upon  the  sides  of  the 
tongue,  jagged  and  sharp  teeth  irritating  the  parts  may  be  supposed 
to  have  some  influence  in  its  localization  ;  such  teeth,  under  all  cir- 
cumstances, should  be  removed  or  smoothly  dressed. 

In  the  treatment  of  scirrhus  of  the  tongue  by  amputation,  several 
modes  are  employed.  One,  that  of  the  French  school,  is  by  means 
of  an  instrument  known  as  the  ecraseur  of  Chassaignac.  This  is 
simply  a  delicate  chain  arranged  from  a  handle,  which  little  by  little 
crushes  off  the  part.  Another  mode,  that  of  strangulation,  consists 
in  the  introduction  of  circumscribing  ligatures,  which,  being  drawn 
tightly,  cutoff  all  circulation  from  the  diseased  part,  thus  compelling 
its  separation.*  Another  means  of  treatment  widely  employed,  and 
in  instances  recommended  by  very  high  authority,  consists  in  the 
use  of  caustic  remedies ;  of  these  there  is  a  great  variety, — arsenic, 

toms  subsided,  the  patient  recovered,  and  is  still  in  good  health, — eleven 
years  after  the  operation. 

"  '  Caroline  C,  aged  thirty-five,  a  married  woman,  and  the  mother  of  three 
children,  was  admitted,  February,  1855,  into  Middlesex  Hospital,  under  the 
care  of  Mr.  De  Morgan.  She  was  subject  to  dyspepsia;  but  during  the  last 
few  years  she  had  been  in  rather  better  health.  She  had  broken  teeth  on  the 
right  side  of  her  mouth,  which  had  irritated  the  tongue.  Two  years  before  her 
admission  she  noticed  that  her  tongue  was  sore,  and  a  year  ago  a  lump  began 
to  form  in  it.  Mr.  De  Morgan  removed  the  right  side  and  tip  of  the  tongue 
by  ligature.  He  made  an  incision  in  the  median  line  beneath  the  jaw,  and 
dissected  his  way  upward,  and  then,  having  passed  the  ligature,  tied  it  over 
a  wooden  bridge,  which  was  fixed  as  a  sort  of  tourniquet.  In  ten  days  or  a 
fortnight  it  had  separated.  On  March  19  both  the  wound  below  the  jaw 
and  that  of  the  tongue  were  quite  healed.  There  was  then,  however,  suspi- 
cious hardening  about  the  cicatrix.  The  disease  soon  afterward  returned  in 
the  stump,  and  in  the  course  of  a  few  months  the  woman  died.' 

"  '  Daniel  H.,  aged  forty-six,  was  admitted,  November  2,  1860,  into  St. 
Thomas's  Hospital,  under  the  care  of  Mr.  McMurdo.  He  stated  that  twelve 
months  ago  he  experienced  a  soreness  of  his  tongue  on  the  left  side,  which 
he  imagined  was  due  to  irritation  of  some  decayed  teeth.  Several  had  been 
removed  in  consequence,  but  nothing  was  done  for  the  tongue.  The  ulcer  in 
the  latter  grew  more  painful,  and  five  months  ago  the  glands  below  the  jaw 
began  to  enlarge.  There  is  at  present  an  ulcer  on  the  left  and  under  side  of 
the  tongue.  This  half  of  the  tongue  is  hardened,  swollen,  and  very  painful  ; 
and  he  speaks  with  great  diflBculty,  from  pain  in  moving  the  tongue,  which 
is  also  not  able  to  be  much  moved,  from  being  swollen  and  tied  down  by  the 
ulceration  and  induration.  He  suffers  a  great  deal  of  pain.  His  health  has 
generally  been  good,  and  he  says  that,  except  for  the  local  distress,  he  feels 
well.  He  is,  however,  very  sallow,  haggard,  and  emaciated.'  " 
*  See  operations  on  a  succeeding  page. 


THE   TONGUE  AND   ITS  DISEASES.  773 

however,  forming  the  base  of  most  of  them.  No  remedies  require  to 
be  used  with  more  judgment  and  caution.  If  the  practitioner  desires 
to  try  a  caustic,  my  own  experience  would  suggest  chloride  of  zinc : 

R. — Zinci  chloridi, 

Aluminis  pulveris,  aa  gr.  v; 
Acidi  tannici,  gr.  ij  ; 
Ferri  persulphatis,  gr.  iij  ; 
Glycerinae,  q.  s.  for  a  paste.     M. 

To  apply  this  paste,  draw  the  tongue  forward,  bold,  and  dry  it 
carefully  in  a  napkin.  Lay  some  crystals  of  zinc  on  the  part,  and 
cover  over  with  the  paste.  This  may  be  allowed  to  remain  as  long 
as  the  tongue  can  be  kept  dry.  Finally,  wash  the  debris  away,  and 
the  application  is  completed. 

It  may  happen,  after  such  an  application,  that  severe  general 
glossitis  will  supervene ;  this  will  be  unfortunate,  and  will  imply 
that  much  more  harm  than  good  has  been  done.  In  making  a 
caustic  impression  under  such  circumstances,  the  parts  should  be 
quickly  killed,  not  excited  and  provoked. 

.  The  galvanic  cautery,  a  means  suggested  originally  by  Heider, 
and  lately  made  quite  practical  by  Hilton,  is  thought  by  many  to  be 
greatly  preferable  to  the  potential  cauterants  :  this  consists  of  a  long, 
delicate-bladed  forceps  transmitting  copper  wires,  which,  being 
applied  to  the  part  to  be  acted  upon,  are  instantly  heated  by  the 
galvanic  current,  thus  destroying  the  vitality  of  the  part  outright. 

Injection  of  persulphate  of  iron  is  still  another  means  much  em- 
ployed and  commended.  My  own  experience  with  it,  however,  has 
not  led  me  to  look  upon  it  as  a  specific. 

The  arrows  of  Maisonneuve,  tipped  with  zinc,  may  be  used  by 
those  who  do  not  fear  a  resulting  inflammation.  Two,  three,  or 
more  of  these  arrows  may  be  made  to  circumscribe  the  tumor,  pre- 
cisely as  practiced  by  this  surgeon  in  his  operations  upon  the  mam- 
mary gland. 

Epithelioma.* — Except  as  situated  upon  the  lower  lip,  in  no  situ- 
ation has  the  author  more  frequently  met  with  epithelioma  of  cancer- 

*  To  the  histologist,  who,  judging  entirely  of  the  character  of  a  patho- 
logical new  formation  by  its  cell  expression,  the  distinction  here  assumed 
between  scirrhus  and  epithelioma  will  serve  to  exhibit  the  author  as  not 
accepting  the  assumed  identity  of  the  conditions.  What  he  has  to  say  on  this 
subject  will  be  found  in  the  chapters  on  Tu7nors. 


774  ORAL  DISEASES  AND  SURGERY. 

ous  expression  than  upon  the  tongue.  Situated  upon  the  sides  and 
along  the  fraenum,  the  disease  is  commonly  first  noticed  as  an  irreg- 
ular puckered  patch  of  more  or  less  hardness,  and  almost  from  the 
very  beginning  has  associated  with  it  a  characteristic  pain.  More 
frequently  than  otherwise,  instead  of  one  patch,  a  sufficiently  close 
observation  will  discover  the  affected  side  studded, — a  matter  which 
is  not  long  in  being  made  evident  enough  to  the  patient.  After  a 
time,  differing  in  different  individuals,  these  patches  sprout  forth  the 
giant  granulations  so  characteristic  of  this  disease,  the  surface  of  the 
sore  becoming  foul  and  ragged,  and  inclining  to  spread  over  neigh- 
boring parts.  Ill  a  case  at  present  under  the  care  of  the  writer,  in 
which  preparation  is  being  made  for  the  amputation  of  the  full 
tongue,  the  disease  exists  as  an  infiltration,  involving  the  entire  right 
half,  but  not  passing  the  raphe. 

In  no  cases  of  disease  does  there  seem  to  exist  greater  reluctance 
on  the  part  of  the  general  practitioner  to  the  admission  of  the  exist- 
ence of  a  fatal  malady  than  in  this  of  epithelioma  of  the  tongue ;  and 
this,  perhaps,  is  not  to  be  wondered  at,  seeing  that  not  unfrequently 
an  ulcer  of  such  signification  will  lie  in  a  dormant  condition  for  a 
period  of  several  months,  looking  to  the  inexperienced  scarcely  as 
formidable  as  a  syphilitic  sore.  Such  oversight  is  always  of  lament- 
able consequence,  as  tlius  the  most  promising  period  for  the  em- 
ployment of  operative  means  has  been  suffered  to  pass  without 
advantage. 

Cancerous  epithelioma,  so  frequently  confounded  with  syphilis, 
is  to  be  distinguished  from  the  latter  expression  not  only  by  its 
location,  but  with  most  assurance  by  its  appearance  ;  the  first  being 
characterized  by  isolated  giant  granulation  of  rough  surface,  the 
latter  by  a  soft,  pasty  base.  The  two  are  really  very  unlike,  and 
should  deceive  no  one:  even  the  primary  chancre  here  sometimes 
found  bears  no  resemblance  to  epithelial  carcinoma. 

The  progress  of  lingual  epithelioma  of  this  expression  is  of  the 
most  distressing  character:  the  organ  enlarges  and  stiffens,  masti- 
cation and  deglutition  become  functions  of  most  difficult  and  painful 
performance,  the  saliva  dribbles  constantly  over  the  chin,  and  the 
patient  finally  perishes  from  starvation  and  exhaustion. 

Cancerous  epithelioma  of  the  tongue  must  either  have  attempted 
with  it  the  most  radical  extirpation,  or  be  soothed  into  quiet,  and 
into  such  abeyance  as  is  possible  to  be  secured.  Of  the  latter  means, 
advantage  has  been  taken  of  a  partial  paralysis,  securing  immunity 
from  pain  through  section  of  the  lingual  nerve ;  while  it  has  also 


THE    TONGUE  AND   ITS  DISEASES.  775 

been  deemed  that  much  control  over  the  progress  of  the  disease 
has  been  secured  by  ligation  of  the  lingual  artery  of  the  affected 
side. 

In  the  practice  of  the  author,  where  operative  means  of  any  class 
have  not  been  thought  advisable,  the  patients  have  expressed  them- 
selves as  receiving  the  greatest  relief  from  the  local  employment,  by 
means  of  an  atomizer,  of  the  following  combination  : 
B. — Acidi  carbolici  fluidi,  5j  5 
Sodse  sulphitis,  5J  ; 
Aquse,  ^x. 

Systemic  lingual  epithelioma  most  frequently  makes  its  appear- 
ance either  at  the  side  of  the  base  of  the  organ  or  near  the  tip. 
Frequently,  however,  where  jagged  teeth  exist  in  the  arch,  it  may 
arise  as  an  abrasion,  the  location  being  without  doubt  influenced 
by  the  irritant.  Such  a  lesion  is  not  apt  to  be  appreciated  in  its 
true  character  until  its  refusal  to  heal  after  the  extraction  of  the 
offending  tooth  is  noticed.  Still  another  cause  of  localization  in 
this  direction  arises  from  a  malarticulation  of  the  posterior  teeth, 
the  tongue  on  each  occlusion  being  caught  and  fretted.  The 
peculiar  articulation  referred  to  is  to  be  seen  when  the  molars  of 
both  jaws  incline  inward,  striking  above  at  the  buccal  angle  and 
leaving  a  space  with  the  base  looking  inward.  The  author  has  at 
the  present  time  under  his  care  two  cases  of  lingual  epithelioma 
which  have  been  thus  located. 

Tubercle. — Scrofula,  as  a  dyscrasia,  differs  from  tuberculosis  in 
not  being  the  expression  of  a  materia  peccans.  Tubercle  repre- 
sents a  specific  condition,  the  scientific  cure  of  which  must  lie  in 
the  discovery  of  an  antidotal  specific.  Tubercle  has  been  discov- 
ered as  a  deposit  in  almost  every  organ  of  the  body,  being,  how- 
ever, as  uncommon  to  the  tongue  as  it  is  the  reverse  to  the 
lungs.  The  existence  of  lingual  tubercular  tumor  is  not,  however, 
to  be  doubted,  the  microscope  revealing  all  the  elements  of  the 
expression  so  fully  studied  in  the  examinations  of  Langhaus.  A 
tubercular  tumor  of  the  tongue  finds  its  diagnosis  most  simply  in 
association:  the  finding,  for  example,  of  tubercle  in  the  lungs,  the 
mesentery,  or  other  parts.  Also,  when  it  appears  in  children,  it  is 
to  be  judged  from  its  so  frequent  association  with  scrofulosis.  The 
child  will  be  likely  to  have  tumid,  pouting  lips,  the  lax,  protuberant 
abdomen,  etc.  Still  again,  as  time  advances,  the  diagnosis  becomes 
verified  by  the  rapid  tendency  to  break  down  and  create  an  indolent 
resisting  ulcer. 


776  ORAL  DISEASES  AND   SURGERY. 

In  the  treatment  of  the  tuberculous  tumor  or  ulcer,  the  iodine 
preparations,  by  universal  consent,  have  come  to  be  most  relied  on, 
in  this  medicine  being  found  the  nearest  approach  to  a  specific. 
In  the  absence  of  a  complete  specific,  however,  it  is  most  important 
to  afford  to  the  vital  force  the  greatest  possible  amount  of  resistive 
power ;  and  this  is  to  be  done  only  by  an  attention  to,  and  an  ob- 
servance of,  those  common  hygienic  and  dietetic  laws  which  keep 
well  people  in  robust  health. 

The  local  treatment  of  lingual  tuberculosis  consists  in  the  use  of 
stimulating  applications  to  the  part,  the  best  of  which  agents  would 
seem  to  be  iodine  in  tincture.  M.  Trelat,  a  French  surgeon,  recom- 
mends touching  such  ulcers  with  the  actual  cautery,  affirming  this 
treatment  to  be  the  only  one  ever  found  of  service  in  his  own  prac- 
tice. 

Cystic  Tumors. — Cystic  tumors  of  the  tongue,  while  not,  as  I 
am  now  satisfied,  frequent,  are  yet  not  sufficiently  rare  to  make 
allusion  to  them  unnecessary.  That  known  as  meliceris  is  round, 
free  from  pain,  and  filled  with  a  glutinous,  honey-like  substance.  A 
peculiarity  of  this  cyst  is  the  fungiform  character  of  its  bottom,  this 
portion  looking  pyogenic.  A  second  order  of  cysts  contains  lymph, 
sometimes  fairly  colloid  in  consistence  and  appearance,  at  other 
times  flaky,  tubercular,  or,  it  may  be,  puriform.* 

*  "  There  is  a  disease  of  the  tongue  which  I  have  seen  every  now  and  then, 
and  which  I  am  sure  is  very  often  mistaken  for  cancer,  though  it  is  of  a  dif- 
ferent nature.  It  is  a  curable  disease,  although  it  looks  like  a  malignant  one 
in  many  respects.  The  first  thing  of  which  the  patient  complains  is  enlarge- 
ment of  the  tongue,  with  some  pain.  On  examination,  you  find  a  tumor  in 
one  part  of  it,  not  very  well  defined,  nor  with  any  distinct  margin.  It  is  a 
softish  tumor,  and  increases  in  size,  and  perhaps  another  tumor  appears  in  a 
diflferent  part  of  the  tongue,  and  that  increases  also.  There  may  be  three  or 
four  of  these  soft  elastic  tumors,  with  no  very  defined  margins,  in  various 
parts  of  the  tongue.     This  is  the  first  stage  of  the  disease. 

"  In  the  second  stage  there  is  a  small  formation  of  matter  in  one  of  these 
tumors, — a  little  abscess,  which  breaks  externally,  discharging  two  or  three 
drops  of  pus.  When  the  abscess  has  burst  it  does  not  heal,  but  another  forms 
in  one  of  the  other  tumors.  These  abscesses  may  assume  the  form  of  ulcers, 
and  the  ulcers  have  a  particular  appearance.  In  the  first  instance  it  is  a  very 
narrow  streak  of  ulceration,  but  on  introducing  a  probe  you  find  that  the 
ulcer  is  the  external  orifice  to  a  sort  of  fissure  in  the  tongue.  The  probe 
passes  in  obliquely  ;  the  tongue  is,  as  it  were,  undermined  by  the  ulcer,  a  flap 
of  the  substance  of  the  tongue  being  over  it. 

"  The  disease  n.ow  becomes  more  painful,  and  at  last  the  ulcers  may  spread 
externally.     In  some  instances  they  occujiy  a  very  considerable  portion  of  the 


THE   TONGUE  AND  ITS  DISEASES.  777 

A  form  of  cystic  tumor,  being  a  cystiform  hypertrophy  of  a  cir- 
cumvallate  papilla,  is  met  with  occasionally  on  the  back  part  of  the 
dorsum.  These  tumors  have  been  known  to  attain  the  size  of  a 
walnut.  To  the  touch  they  are  very  solid,  the  walls  being  greatly 
indurated.  If  satisfied  that  there  is  no  malignant  association,  the 
practitioner  may  puncture  the  sac  and  introduce  a  tent.  Iodine 
may  be  used  both  externally  and  by  injection.     Ranular  cysts,  fre- 


surface  of  the  tongue,  but  generally  they  burrow  internally,  and  do  not  spread 
much  toward  the  surface.  This  is  a  very  distressing  state  of  things,  and  a 
man  may  remain  in  this  state  for  a  long  time.  The  glands  of  the  neck  do 
not  become  atfected,  nor  does  the  general  health  suffer,  except  from  the  diffi- 
culty of  swallowing  food.  This  is  one  inconvenience  experienced  by  the 
patient;  and  he  also  labors  vmder  a  difficulty  of  articulation.  The  tongue, 
from  its  enlarged  state,  may  become  stiff,  not  sufiiciently  pliable  for  the  pur- 
poses of  speech,  and  the  patient  either  speaks  thick  or  lisps. 

"  In  some  instances  the  disease  may  be  relieved  by  a  course  of  sarsaparilla, 
with  small  doses  of  bichloride  of  mercury.  A  strong  decoction  of  sarsaparilla, 
with  from  a  quarter  to  half  a  grain  of  bichloride  of  mercury,  may  be  taken 
in  the  course  of  the  day.  Of  course,  if  there  be  anything  wrong  in  the  gen- 
eral health,  you  should  endeavor  to  get  that  corrected,  and  attend  especially 
to  the  state  of  the  bowels  and  the  secretion  of  the  liver.  If  the  secretions  of 
the  digestive  organs  be  unhealthy,  a  dose  of  senna  and  salts  may  be  given 
every  other  morning,  and  blue  pill  every  other  night.  When  the  patient  is 
brought  into  this  state,  one  remedy,  as  I  have  said,  is  sarsaparilla  with 
bichloride  of  mercury ;  but,  according  to  my  experience,  this  is  not  the  best 
remedy.  The  remedy  best  adapted  for  these  cases  is  a  solution  of  arsenic. 
Give  the  patient  five  minims  three  times  daily,  in  a  draught,  gradually  in- 
creasing the  dose  to  ten  minims.  It  should  be  taken  in  full  doses,  so  that 
it  may  begin  to  produce  some  of  its  poisonous  effects  on  the  system.  When 
it  begins  to  act  as  a  poison,  it  will  show  itself  in  various  ways.  Some- 
times there  is  a  sense  of  heat,  a  burning  pain  in  the  rectum ;  sometimes 
griping,  purging,  and  sickness,  and  nervous  tremblings.  A  patient  who  is 
taking  arsenic,  especiallj'  in  pretty  large  doses,  ought  to  be  carefully  watched. 
At  first  you  may  see  him  every  two  or  three  days,  and  then  every  day ;  and 
as  soon  as  the  arsenic  begins  to  operate  as  a  poison,  leave  it  off.  When  this 
effect  is  produced,  the  disease  of  the  tongue  generally  gets  well ;  but  at  any 
rate  leave  off  the  arsenic,  and  the  poisoning  will  not  go  too  far ;  it  will  do  no 
harm.  If,  after  a  time,  you  find  that  the  disease  is  relieved,  but  not  entirely 
cured,  you  may  try  another  course  of  arsenic.  Perhaps  it  may  take  a  consid- 
erable time  to  get  the  tongue  quite  well.  Sarsaparilla,  with  the  bichloride 
of  mercury,  may  be  given  at  one  time  ;  and  at  another,  ar.senic.  You  cannot 
give  either  of  these  remedies  forever,  and  indeed  the  arsenic  can  only  be  given 
for  a  very  limited  period ;  but  it  is  astonishing  what  bad  tongues  of  this  de- 
scription I  have  seen  get  well  under  these  modes  of  treatment,  especially 
under  the  use  of  arsenic." — Brodie. 


778  ORAL  DISEASES  AND   SURGEBY. 

quently  described  as  lingual  cysts,  are  classified  by  themselves.  (See 
Ranula.) 

Acute  Glossitis. — Acute  inflammation  of  the  tongue,  whether 
of  idiopathic  or  of  traumatic  character,  is  always  to  be  looked  on 
with  concern.     The  causes  inducing  this  condition  are  various. 

Viewed  as  a  distinct  condition, — and  this  view,  no  matter  what 
the  cause,  will  always  force  itself  on  the  attention  of  the  practitioner 
when  called  to  a  case, — the  most  urgent  necessity  will  nearly  always 
be  felt  for  a  treatment  that  shall  abort  or  resolve  the  phenomena  as 
quickly  as  possible.  It  is  true  that  all  glossal  inflammations  are  not 
dangerous  ;  but  they  all  inspire  with  a  sense  of  danger. 

Acute  glossitis,  idiopathic  in  form,  commonly  begins  with  a  sense 
of  enlargement  and  stiffness  of  some  part  of  the  organ,  generally 
the  anterior  part;  this  soon  becomes  red,  painful,  and  percjeptibly 
swollen.  At  this  stage  the  condition  may  rest,  and  after  some  little 
time  commence  to  decline.  On  the  other  hand,  a  single  hour  may 
witness  the  spread  of  the  inflammation  to  an  extent  which  shall 
threaten  or  perhaps  produce  suffocation.  In  still  other  instances 
the  advance  is  gradual ;  the  circulation  sympathizing,  the  pulse  grows 
rapid  and  irritable,  the  skin  becomes  hot,  only  to  decline  to  the  cold 
sweating  stage;  and  suppuration  or  perhaps  gangrene  terminates 
the  action.* 

*  "  Glossitis,  Acute. — Michael  M.,  aged  thirty-six  years,  employed  as  a  boat- 
man by  the  Barrow  Navigation  Company,  presented  himself  at  the  Meath  Street 
Dispen.«ary,  Dublin,  on  the  14th  of  January,  1871.  His  appearance  was  charac- 
teristic of  the  affection  from  which  he  suffered.  His  countenance  was  anxious, 
the  tongue  protruded  between  the  teeth,  his  speech  was  thick,  or  what  might  be 
termed  the  glossitic speech  ;  his  breathing  was  distressed.  On  inquiry,  he  ascer- 
tained that  the  man  had  got  a  severe  wetting  some  days  previously,  and  had 
his  feet  also  immersed  in  water.  He  shivered,  and  felt  a  soreness  at  the  root 
of  the  tongue.  He  had  not  been  taking  any  medicine,  and  up  to  the  time  of 
severe  wetting  was  in  robust  health.  In  addition  to  the  symptoms  detailed, 
he  had  a  dribbling  of  saliva  from  the  mouth,  with  headache  and  dysphagia. 
The  pain  in  the  tongue,  as  the  disease  advanced,  was  described  by  him  as  of 
a  stinging  nature.  On  examination,  he  (Mr.  Croly)  found  the  tongue  cov- 
ered with  a  white  exudation,  like  a  false  membrane.  The  organ  was  large, 
protruded,  and  exquisitely  tender  to  the  touch.  The  sublingual  space  was 
infiltrated  and  chemosed,  and  the  fringe  beneath  the  tongue  resembled  a 
cock's  comb.  The  tonsillitic  regions  were  natural,  and  bore  pressure  without 
causing  any  uneasiness.  He  got  the  patient  to  open  his  mouth  sufficiently  to 
enable  him  to  introduce  his  little  finger,  and  the  man  winced  when  he  de- 
pressed his  tongue.  He  observed  that  the  palate  and  tonsillitic  regions,  as 
seen  internally,  were  not  in  the  slightest  degree  altered.     He  considered  from 


i 


THE    TONGUE  AND   ITS  DISEASES.  779 

The  dangerous  character  of  a  severe  glossitis  demands  the  most 
energetic  treatment.     Leeches  direct  to  the  organ  or  beneath  the 

the  patient's  general  symptoms,  and  the  infiltrated  condition  of  the  tongue, 
caused  by  the  exudation  of  lymph  in  addition  to  the  engorgement  with  blood 
and  serum,  that  no  time  should  be  lost  in  giving  him  relief  by  the  knife.  He 
accordingly  introduced  a  sharp-pointed  bistoury  far  back,  and  made  a  free 
incision  at  each  side,  parallel  with  the  raphe.  The  wounds  gaped  and  bled 
freely,  and  the  patient's  speech  became  suddenly  better.  He  next  punctured 
freely  the  chemosed  sublingual  space.  A  warm  bath  and  a  purgative  draught 
were  prescribed,  and  he  warned  the  man  against  cold,  and  recommended  him 
to  come  into  hospital,  but  he  declined.  On  the  following  day  he  culled  at  the 
dispensary,  and  was  much  improved.  The  tongue  was  still  tender  to  the 
touch,  but  the  symptoms  were  so  much  relieved  that,  notwithstanding  his 
advice  to  the  contrary,  he  returned  by  boat  to  the  country  that  evening,  and 
he  had  heard  nothing  of  him  since.  The  notes  of  the  next  case  to  which  he 
would  call  their  attention  were  sent  to  him  by  Dr.  Barry,  of  Kanturk.  He 
visited  a  man,  aged  forty,  whose  respiration,  articulation,  and  deglutition 
were  very  painfully  affected.  His  tongue  protruded  between  his  teeth,  and 
was  so  engorged  as  to  fill  all  the  space  up  to  the  palate  ;  and  the  tissues  from  the 
chin  to  the  larynx  were  infiltrated.  With  some  difficulty,  Dr.  Barry  intro- 
duced a  long  and  narrow  bistoury  on  the  flat,  and,  having  turned  the  blade  on 
its  edge,  he  made  two  longitudinal  incisions  parallel  to  the  raphe,  with  in- 
stantaneous relief.  There  was  a  copious  flow  of  blood,  which  relieved  the 
danger  of  impending  suffocation,  and  the  patient  recovered  in  a  few  days,  and 
was  now  in  good  health.  The  notes  of  the  following  three  cases  were  kindly 
given  to  him  by  Dr.  Leeper,  of  Keady.  Dr.  Leeper  called  the  cases  '  Glossitis.' 
The   first  was  followed  by  an  attack  of  delirium  tremens,  and  after  that  by 

diffuse  inflammation  of  the  left  leg.   Mr.  ,  of  full  habit  of  body,  a  free  liver, 

of  intemperate  habits,  dined  at  a  club  with  seven  friends  on  New  Year's  eve. 
He  left  the  hot  dining-room  late,  and  drove  home,  a  distance  of  .six  miles,  the 
night  being  bitterly  cold  and  frosty.  Next  morning  he  awoke  with  sore 
throat,  some  difficulty  of  swallowing,  and  had  a  dry,  parched,  and  swollen 
tongue.  These  symptoms  rapidly  increased,  and  Dr.  Leeper  was  asked  to  see 
him  at  ten  o'clock  a.m.  The  tongue  was  then  greatly  swollen,  filling  up  the 
mouth,  and  protruding  an  inch  between  the  teeth.  It  was  of  a  dark-brown, 
almost  mahogany,  color.  The  sublingual  glands  were  swollen,  and  the  sub- 
lingual spaces  filled  up  to  a  level  with  the  incisors.  The  submaxillary  glands 
were  not  much  affected.  It  was  impossible  to  see  either  the  tonsils  or  fauces  ; 
but  the  roof  of  the  mouth  was  covered  with  red  erythematous  patches.  When 
the  tongue  was  well  moistened  he  could  swallow  and  speak  without  much 
difficulty.  Six  leeches  were  applied  to  the  under  surface  of  the  tongue  and 
sublingual  space.  They  rapidly  filled  themselves,  and  from  the  bites  there 
was  a  very  considerable  flow  of  blood,  which  gave  immediate  relief.  Before 
two  hours  he  could  keep  the  tongue  in  the  mouth,  and  swallow  with  ease.  Dr. 
Leeper  considered  that  the  leeching,  purging,  and  sudden  withdrawal  of  his 
accustomed  stimulant  and  food  brought  on  an  attack  of  delirium  tremens. 


780  ORAL  DISEASES  AND   SURGERY. 

jaw,  bleeding  from  the  arm,  catharsis,  diaphoresis, — any  or  all  of 
these  means  are  successively  to  be  brought  into  requisition.  A  plan 

The  next  case  was  one  of  acute  glossitis,  treated  by  free  incisions  on  the  dor- 
sum of  the  tongue.  P.  R.,  a  farm-laborer,  was  attending  a  corn-mill,  getting 
oatmeal  prepared.  When  there,  he  assisted  the  kilnman  in  turning  the  oats 
when  drying,  got  into  a  profuse  perspiration,  and  soon  afterward  exposed 
himself,  on  a  cold,  biting  day  in  March,  and  was  chilled.  This  was  followed 
by  swelling  of  the  tongue,  and  difficulty  of  swallowing.  Dr.  Leeper  saw  him 
the  next  day.  The  tongue  was  greatly  swollen,  especially  at  the  back  part ; 
there  was  an  abundant  flow  of  saliva  from  the  mouth,  and  the  surface  of  the 
tongue  was  covered  with  a  dirty-white,  creamy-looking  paste.  He  was  speak- 
ing thick,  and  said  he  would  soon  choke  if  not  relieved.  There  was  no  en- 
largement of  the  tonsils  or  the  submaxillary  glands.  Dr.  Leeper  made  with 
a  lancet,  the  only  instrument  he  had  with  him,  two  incisions  on  the  dorsum 
of  the  tongue,  parallel  to  the  raphe.  There  was  a  discharge  of  four  or  five 
ounces  of  blood  and  serum  from  these  incisions.  He  received  a  message  next 
day  to  say  that  the  man  was  much  worse,  and  on  visiting  him  found  the 
tongue  more  swollen,  protruding  from  the  mouth,  and  that  deglutition  and 
speech  were  more  difficult  than  on  the  day  before.  He  introduced  a  sharp- 
pointed  bistoury,  and  made  two  long  and  pretty  deep  incisions  on  the  dorsum 
from  the  base  to  the  tip  of  the  tongue.  These  bled  profusely,  and  gave  im- 
mediate relief,  and  the  next  day  the  patient  could  swallow  without  difficulty, 
but  the  speech  was  thick.  His  recovery  from  this  time  was  rapid.  In  the 
third  of  Dr.  Leeper's  cases,  the  patient  was  forty-five  years  of  age.  After 
exposure  to  cold  he  complained  of  pain  and  deafness  in  the  right  ear,  and 
these  were  soon  followed  by  difficult}'  of  speaking.  These  symptoms,  after 
having  lasted  upward  of  a  fortnight,  were  succeeded  by  rapid  swelling  of  the 
right  side  of  the  tongue.  When  Dr.  Leeper  saw  him,  there  was  a  profuse 
flow  of  saliva,  so  much  so,  that  he  thought  he  must  be  laboring  under  the 
influence  of  mercury ;  but  there  was  no  mercurial  fetor,  nor  were  the  gums 
affected.  The  right  side  of  the  tongue  was  as  much  aff"ected  as  it  could  be, 
but  the  left  was  not  engaged.  The  tonsils  were  not  enlarged  ;  neither  the  sali- 
vary nor  the  submaxillary  glands  were  swollen.  The  root  of  the  tongue  was 
hard  and  swollen.  Any  attempt  to  swallow  was  followed  by  a  squirt  through 
the  nose  and  mouth,  with  coughing.  It  seemed  as  if  the  epiglottis  could  not 
act,  and  that  the  fluid  passed  into  the  larynx.  Some  milk  was  injected  (by 
means  of  a  large  elastic  catheter  attached  to  an  elastic  bag)  into  the  cesopha- 
gus.  He  sometimes  succeeded  in  swallowing,  but  the  attempt  far  oftener 
failed,  and  was  very  distressing  to  him.  Dr.  Leeper  made  a  free  incision,  on 
the  dorsum,  from  the  back  to  the  tip  of  the  tongue  on  the  right  side,  but  the 
discharge  of  blood  was  inconsiderable,  less  than  he  could  have  supposed  from 
the  extent  of  the  incision.  Fomentations  with  hot  chamomile-tea  were  used 
and  kept  in  the  mouth,  and  his  health  supported  as  well  as  possible  with  milk 
and  beef-tea.  Next  day  he  was  worse,  and  Dr.  Leeper  made  a  still  deeper  and 
more  extensive  incision  on  the  right  side  of  the  tongue.  There  was  no  dis- 
charge of  blood  or  serum,  at  least  not  more  than  two  ounces,  and  no  relief 


i 


THE    TONGUE  AND   ITS  DISEASES.  781 

of  treatment,  as  reliable  as  any  in  character,  is  as  follows  :  place 
on  the  back  of  the  neck  a  cataplasm  of  mustard  and  red  pepper; 
put  the  feet  in  water  as  hot  as  can  be  endured ;  give  a  full  dose 
of  sulphate  of  magnesia.  If  now  the  disease  does  not  seem  to  be 
held  in  check,  wrap  the  patient  in  shawls  or  in  blankets  and  admin- 
ister spirits  of  Mindererus  until  full  diaphoresis  is  secured.     If  even 

from  it.  Mr.  Young,  of  Monaghan,  saw  the  patient  the  next  day,  and  ad- 
vised leeches  to  the  side  and  under  surface  of  the  tongue.  These  induced 
profuse  bleeding,  which  was  kept  up  by  cold  water  in  the  mouth,  Dr.  Young 
thinking  that  cold  water  promoted  bleeding  from  leech-bites  better  than  hot. 
The  swelling  of  the  tongue  subsided  at  once  after  the  leeching,  but  the  right 
side  of  it  remained  thicker  and  harder  than  the  left,  and  the  man's  speaking 
was  still  difficult  and  imperfect.  Mr.  Croly  proceeded  to  say  that  it  was 
superfluous  to  go  into  the  subject  more  fully,  as  it  had  been  already  discussed 
at  a  previous  meeting.  He  would  only  state  that  he  thought  the  case  he  had 
detailed  was  a  very  well-marked  case  of  idiopathic  glossitis.  The  man  work- 
ing on  a  river  and  getting  a  severe  wetting,  not  taking  any  mercury,  the 
tongue  becoming  greatlj'  swollen,  the  characteristic  voice,  the  absence  of  any 
tonsillitic  inflammation, — all  these  features  showed  that  it  was  a  typical  case 
of  idiopathic  glossitis. 

"  Mr.  Richardson  said  he  had  a  case  of  this  kind  a  short  time  ago  in  the 
Adelaide  Hospital.  There  was  rapid  swelling  of  the  right  side  of  the  tongue 
and  chemosis  of  the  floor  of  the  mouth.  In  that  case  he  not  only  made  an 
incision  from  the  base  to  the  point  of  the  tongue,  along  the  dorsum,  but  he 
also  made  a  few  punctures  in  the  chemosis  on  the  floor  of  the  mouth,  and  the 
man  was  well  in  a  few  days.  An  exfoliation  of  mucous  membrane  followed, 
which,  however,  did  not  interfere  with  recovery.  As  there  was  some  doubt 
regarding  the  period  at  which  the  treatment  by  long  incisions  was  introduced, 
he  wished  to  state  that  he  had  found  in  the  Memoirs  of  the  French  Academy 
of  Surgery  several  cases  of  this  kind  recorded.  In  one  of  these  cases,  pub- 
lished by  De  la  Motte  in  1725,  tbe  tongue  became  greatly  swollen  in  less  than 
five  liours.  It  soon  filled  the  mouth,  and  protruded  from  between  the  teeth. 
Bleedings  from  the  jugular  vein,  arm,  and  foot  were  performed  without  relief, 
but  a  rapid  cure  followed  three  deep  incisions  along  the  dorsum,  extending 
from  base  to  apex.  The  patient  could  speak  in  an  hour  after  the  incisions 
were  made.  In  another  case,  that  occurred  in  1744,  rapid  swelling  of  one  side 
of  the  tongue  took  place  in  a  woman.;  respiration  was  obstructed,  and  deglu- 
tition impossible.  It  was  cured  by  one  long,  deep  incision.  Louis  mentions 
a  case  that  occurred  in  the  military  hospital  at  Metz  in  the  year  1740.  The 
tongue  became  spontaneously  swollen.  Alexander  Benedictus,  wlio  published 
the  case,  mentioned  that  M.  Casteras,  the  senior  physician  of  the  hospital, 
directed  him  to  scarify  the  tongue  lightly.  This,  however,  was  not  sufficient, 
and  the  patient  died  in  two  days  in  consequence  of  the  swelling.  As  Louis 
truly  observes,  life  might  have  been  saved  by  a  couple  of  deep  incisions  along 
the  dorsum  of  the  tongue." 


782  ORAL   DISEASES  AND   SURGERY. 

yet  control  is  not  secured,  let  ten,  twenty,  or  thirty  American 
leeches,  or  a  third  of  the  number  of  Swedish,  be  placed  beneath  the 
jaw.  If  the 'action  is  still  unconquered,  blood  pro  re  uata  is  to  be 
taken  from  the  arm,  and  the  tongue  itself  is  to  be  freely  incised.  If 
yet  the  swelling  goes  on,  and  suffocation  be  threatened,  laryngotomy 
or  tracheotomy  becomes  a  necessity.     (See  these  operations.)* 

*  "  Mr.  J.  Z.  Laurence  exhibited  before  the  North  London  Medical  Society 
the  tongue  of  a  woman  who  had  died  of  acute  inflammation  of  the  organ. 
She  had  been  under  Mr.  Laurence's  care  for  acute  rheumatism,  when,  on  the 
evening  of  the  5th  November,  he  was  called  to  her,  and  found  her  sitting  up  in 
the  bed,  with  a  countenance  expressive  of  the  greatest  anxiety,  her  face  pale 
and  bedewed  with  sweat;  she  breathed  at  long  intervals,  and  laboriously  ;  pulse 
130.  The  cause  of  this  was  evident ;  she  could  not  open  her  mouth  to  speak, 
for  a  swelling  of  the  left  half  of  the  tongue,  which  was  red,  dry,  and  glassj'. 
On  the  night  of  the  2d  and  3d  she  had  had  severe  rigors.  Mr.  Laurence  at 
once  made  three  free  incisions  into  the  tongue,  and  about  half  a  pint  of  blood 
escaped.  About  two  hours  after  the  bleeding  had  ceased,  the  submaxillary 
region  began  to  swell,  twelve  leeches  were  applied,  and  on  the  following 
morning  the  right  half  of  the  tongue  began  to  swell,  and  by  the  afternoon  it 
had  attained  full  as  great  a  size  as  the  left.  With  this  was  a  corresponding 
engorgement  of  the  tissues  about  the  jaw;  the  local  depletion  had  had  very 
little  effect  in  reducing  the  swelling  of  the  left  side  of  the  tongue;  generally 
she  was  worse  ;  rigors  now  came  on,  and  the  pulse  intermitted  three  or  four 
beats.  Mr.  Quain  saw  her,  and  proposed  incising  the  right  half  of  the 
tongue,  but  both  patient  and  friends  objected.  Mr.  Laurence  saw  her  the 
last  time  alive  the  same  night ;  her  surface  was  deadly  cold  ;  pulse  not  percep- 
tible at  the  wrist,  yet,  strangely  enough,  the  respiration  went  on  tranquilly, 
though  feebly.  Mr.  Laurence  at  once  perceived  that  she  was  dyijig  of  slow 
asphyxia,  and  that  her  only  chance  was  in  tracheotomy  ;  this  was  proposed 
with  more  impressive  force  than  a  surgeon  almost  dare  do.  She  and  her 
husband  doggedly  refused.     Next  morning  she  was  dead. 

"  Autopsy. — No  organic  disease  was  discoverable.  The  whole  of  the  tongue 
was  swollen,  pale,  and  soft  from  maceration  in  a  puro-serous  fluid,  which  infil- 
trated the  substance.  The  superior  apertui-e  of  the  larynx  was  greatly 
narrowed  by  serous  efifusion  ;  the  rima  glottidis  to  a  less  extent;  below  this 
point  the  whole  of  the  trachea  was  perfectly  unobstructed  ;  the  submaxillary 
region  and  anterior  triangles  of  the  neck  were  infiltrated  with  a  serous  fiuid, 
which,  among  the  suprahyoid  muscles,  liad  assumed  a  purulent  aspect.  The 
lungs  were  singularly  healthj^  ;  the  heart,  kidneys,  and  bladder  presented  no 
signs  of  disease. 

"  From  the  above  facts,  it  follows  that  tracheotomy  would  in  all  probability 
have  saved  the  woman's  life;  and  Mr.  Laurence  believes  he  proposed  it  at  the 
proper  time.  It  is  true  there  wag,  throughout  the  case,  not  one  fit  of  suflToca- 
tion.  On  the  contrary,  she  died  choked  in  the  most  gradual  conceivable 
manner ;  and  were  he  to  meet  with  another  case,  he  would  not  defer  the 
operation  until  the  patient  was  in  his  last  gasp,  as  was  too  commonly  the 


THE   TONGUE  AND   ITS  DISEASES.  783 

Abscess. — In  depraved  and  tainted  conditions  of  the  system, 
abscesses,  of  what  might  be  called  a  cold  character,  occasionally 
form  among  the  deeper  muscles  of  the  tongue;  such  abscesses  are 
not  necessarily  associated  with  any  marked  inflammatory  phe- 
nomena, but  may  have  attention  first  directed  toward  them  by  the 
swelling  which  appears  on  the  under  surface. 

The  proper  treatment  in  these  cases  will  be  found  in  voiding  the 
matter  through  puncture  as  soon  as  fluctuation  is  perceived  ;  otlier- 
Avise  it  has  happened  that  the  pus  has  dissected  its  way  down  the 
neck,  pointing  in  front  of  the  hyoid  bone,  creating  much  derange- 
ment, and  threatening  even  a  fatal  result.  Treat  these  cases  by 
local  stimulating  injections  and  the  internal  administration  of  tonic 
medicines.  Acute  abscess  is  one  of  the  terminations  of  glossitis. 
(See  foot-note  for  illustration.)* 

case,  but  resort  to  it  as  soon  as  he  saw  the  patient  sinking,  previous  measures 
not  having  ameliorated  his  condition.  A  curious  pathological  fact,  which 
Mr.  Laurence  noticed  and  pointed  out  to  Mr.  Phillips,  who  attended  the  case 
with  him,  was  the  successive  and  separate  invasion  of  the  two  halves  of  the 
tongue  by  the  intiammatory  action,  offering  a  remarkable  instance  of  the 
dependence  of  pathological  changes  on  the  anatomical  distribution  of  the 
blood-vessels." 

*  The  following  suggestive  case  of  abscess  of  the  tongue,  ending  fatally 
from  hemorrhage,  is  related  by  Mr.  Ward,  being  presented  before  the  London 
Medical  Society : 

"  E.  T.,  aged  seven,  was  born  with  a  slight  red  enlargement  in  the  centre 
of  the  tongue.  ]Sfo  inconvenience  or  difficulty  in  the  ordinary  motions  of  the 
tongue,  or  in  swallowing,  had  ever  been  experienced;  the  general  health  had 
always  been  good.  In  the  night  of  Sept.  27,  having  been  in  her  usual 
health  at  bedtime,  she  was  attacked  with  pain  and  swelling  under  the  chin 
and  both  sides  of  the  lower  jaw;  slept  very  little,  and  the  following  morning 
had  pain  in  the  tongue,  with  great  difficulty  in  speaking,  or  swallowing  any- 
thing but  liquids.  She  had  an  aperient  powder  at  night,  and  the  lower  jaw 
was  fomented  frequently.  In  this  state  she  continued  for  two  or  three  days, 
and  was  visited  by  me  on  Oct.  1,  when  the  following  appearances  were 
noted  : — Face  flushed  ;  eyes  very  bright ;  countenance  anxious  ;  great  swelling, 
redness,  and  extreme  tenderness  of  the  parts  under  the  lower  jaw ;  very  slight 
swelling  of  the  tongue  itself,  which  is  covered  with  a  thick,  brown  fur ;  is 
unable  to  open  the  mouth  wide,  or  move  the  tongue  beyond  the  teeth,  or  to 
speak,  and  has  great  pain  in  the  mouth  ;  pulse  very  quick  and  sharp;  great 
heat  of  skin,  and  thirst  urgent;  bowels  confined.  Ordered  eight  leeches  to 
be  applied  under  the  chin  ;  to  take,  at  bedtime,  four  grains  of  calomel ; 
James's  powder  and  sugar,  of  each  three  grains;  a  saline  mixture,  containing 
a  scruple  of  nitrate  of  potash ;  one  tablespoonful  every  three  or  four  hours. 

"  Oct.  2.  Slept  more  last  night  than  since  first  attacked  ;  fever  great;  pain 


784  ORAL   DISEASES  AND  SURGERY. 

Neuralgia  of  the  Tongue. — The  only  neuralgia  of  the  tongue 
which  seems  special  and  peculiar  to  the  organ  has  its  seat  about  the 

slightly  relieved;  swelling  and  redness  less;  mouth  nearly  closed ;  was  able 
to  swallow  the  powder  in  Jelly,  but  refuses  the  mixture,  of  which  very  little 
has  been  taken;  bowels  freely  relieved,  evacuations  dark  and  offensive;  to 
take  calomel  and  James's  powder,  of  each  three  grains,  and  jalap,  five  grains, 
at  bedtime  ;  use  a  chloride-of-soda  gargle,  warm,  to  the  mouth,  by  means  of 
a  syringe.     Fluids  taken  in  the  mouth  return  by  the  nose. 

"4th.  Less  fever;  rests  better  at  night;  difficulty  in  swallowing  or  speak- 
ing the  same ;  can  open  the  mouth  sufficiently  to  allow  the  tongue  to  be  seen, 
which  is  nearly  fixed,  very  little  swollen,  and  still  thickly  coated;  the  breath 
extremely  fetid  ;  external  redness  and  swelling  still  considerable ;  the  tender- 
ness great;  pulse  soft,  quick,  and  weak;  the  bowels  act  freely;  was  able  to 
pass  my  finger  into  the  mouth  ;  under  each  side  of  the  tongue  distinct  fluctua- 
tion can  be  felt;  while  pressing  on  the  left  side  the  lining  membrane  gave 
way,  and  was  followed  by  a  profuse  discharge  of  fetid  pus,  mixed  with  blood ; 
the  point  of  the  finger  passed  easily  to  the  depth  of  the  first  joint,  under  the 
tongue,  giving  the  sensation  of  a  large  pulp  cavity ;  the  tongue  not  very 
tender,  can  be  moved  from  side  to  side  by  means  of  a  small  teaspoon,  but  not 
voluntarily.  Apply  strong  poppy  fomentation  frequently,  and  linseed  poul- 
tice ;  continue  the  chloride-of-soda  gargle  under  the  tongue,  with  the  syringe, 
and  take,  of  a  mixture  consisting  of  six  grains  of  quinine,  a  teaspoonful  every 
four  hours ;  give  a  little  port  wine  and  water  frequently,  and  milk  or  thin 
arrowroot  for  drink. 

"  6th.  The  pain  less  since  the  use  of  the  poppy  fomentation,  generally 
sleeping  for  some  hours  after  using  it ;  the  discharge  of  pus  and  saliva  very 
copious  and  offensive ;  lies  with  the  head  on  the  left  side  to  allow  the  free 
exit  of  the  discharge,  otherwise  the  mouth  is  constantly  filled ;  fever  less,  as 
also  the  swelling  and  tenderness  ;  redness  gone  ;  great  debility  and  considera- 
ble wasting  of  the  body  already  ;  can  swallow  fluid,  and  is  eager  for  the  wine  ; 
very  little  quinine  has  been  taken ;  bowels  act  twice  a  day ;  can  open  the 
mouth  wider,  but  is  still  unable  to  protrude  the  tongue,  which  is  cleaner  and 
moister ;  on  slightly  raising  it  by  the  handle  of  a  spoon,  a  large  jagged  open- 
ing may  be  seen  on  the  left  under  side  of  the  lower  jaw,  from  which,  by 
gentle  pressure  under  the  chin,  a  profuse  discharge  of  thick  pus  wells  up,  of 
which  I  pressed  out  at  least  two  ounces  ;  pulse  soft  and  weak.  Continue  the 
external  applications;  apply  the  chloride-of-soda  gargle  frequently  to  the 
mouth  and  under  the  tongue,  with  the  syringe  ;  take  a  mixture  consisting  of 
two  ounces  and  a  half  of  decoction  of  bark,  syrup  of  orange-peel,  and  tincture 
of  bark,  of  each  two  drachms,  a  fourth  part  three  times  a  day;  continue  the 
wine,  and  give  strong  beef-tea  and  arrowroot  frequently. 

"9th.  Altogether  improved;  discharge  less,  but  still  fetid;  takes  fluid 
nourishment  frequently,  and  the  wine  ;  the  general  swelling  and  the  tender- 
ness reduced ;  more  on  the  left  side  under  the  jaw  than  the  right,  and  is  un- 
able to  protrude  the  tongue  farther.  Continue  all  the  applications  and  .the 
mixture. 


THE   TONGUE  AND  ITS  DISEASES.  785 

extreme  tip;  the  pain,  which  is  very  irregular  in  its  coming  and 
going,  is  of  the  most  acute  character,  seeming  indeed  as  if  the 

"  llth.  Has  not  rested  so  well  the  last  two  nights,  and  has  had  more  pain, 
particularly  on  the  right  side,  which  is  more  swollen  and  very  tender,  the 
left  side  being  almost  in  its  natural  state ;  the  discharge  has  been  profuse,  but 
thinner;  the  tongue  is  moist  and  clean;  not  very  tender,  but  less  movable; 
the  opening  under  the  left  side  of  the  tongue  smaller ;  fever  returned  ;  has 
constant  hacking  cough;  not  able  to  swallow  so  well,  or  to  speak  so  as  to  be 
understood.  Apply  six  leeches  under  right  side  of  lower  jaw ;  continue  the 
fomentations  and  poultices ;  also,  bark  mixture  and  port  wine. 

"  12th.  Has  slept  very  little,  from  the  frequent  coughing,  which  tires  her 
very  much  ;  discharge  from  the  mouth  less  and  thinner,  but  still  fetid  ;  emacia- 
tion extreme;  has  changed  the  })osition  of  lying  to  the  right  side  ;  left  angle 
of  the  mouth  drawn  down  ;  the  swelling  and  tenderness  on  the  right  side  very 
much  increased  since  yesterday  ;  feels  soft ;  is  more  prominent  in  the  centre, 
and  appears  pointing  here  ;  the  finger  in  the  mouth  can  detect  very  distinct 
fluctuation  under  the  tongue,  which  is  thickly  coated  and  very  tender;  takes 
very  little  nourishment,  only  a  teaspoonful  at  a  time:  prefers  wine  to  other 
things.     Continue  the  fomentations  and  poultices. 

"  13th.  Has  had  a  bad  night ;  is  very  irritable  and  feverish  ;  mouth  nearly 
closed;  unable  to  examine  the  tongue;  the  swelling  about  the  same;  the 
right  cheek  and  under  side  of  the  jaw  of  a  dusky  red  color,  and  very  shining  ; 
so  tender  that  she  has  again  changed  the  position ;  lying  on  the  left  side  ; 
cough  less  ;  pulse  very  small  and  weak  ;  takes  scarcely  anything ;  discharge 
more  copious,  thicker,  and  slightly  tinged  with  blood  ;  it  now  appears  to  come 
from  the  right  side.  In  the  evening,  while  coughing,  a  large  gush  of  blood 
took  place  from  the  mouth,  mixed  with  pus,  and  flowed  freely  for  more  than 
ten  minutes.  By  applying  ice  internally  and  externally  (which  I  had  directed 
to  be  in  readiness),  the  hemorrhage  was  arrested.  A  cold  lotion  was  applied 
externally,  and  an  alum  gargle  frequently  to  the  mouth. 

"  14th.  Has  slept  very  little;  unable  to  lie  down,  from  the  constant  dis- 
charge of  fetid  pus  and  saliva  from  the  mouth  ;  the  swelling  of  the  right 
cheek  and  side  of  the  jaw  less  ;  very  tender,  of  a  dull, -yellowish  color  ;  able 
to  open  the  mouth  so  as  to  examine  the  tongue,  which  does  not  appear  en- 
larged;  no  power  of  moving  it  herself;  is  thickly  coated  with  a  dark  fur, 
and  when  pressed  upon,  a  profuse  discharge  of  thick  pus  fills  the  mouth  im- 
mediately ;  no  return  of  the  hemorrhage  ;  is  very  pale  and  faint;  pulse  very 
small  and  weak;  has  taken  more  nourishment  since  last  night  than  for  some 
days  before,  such  as  port  wine,  i.^inglass  in  milk,  beef-tea,  jelly,  etc.  Con- 
tinue the  lotion  and  alum  gargle  to  the  mouth  witli  a  syringe.  At  half-past 
seven  P.M.,  in  the  act  of  swallowing  a  small  piece  of  bread-and-butter,  profuse 
hemorrhage  occurred  from  the  mouth,  and  more  than  a  pint  of  blood  was  lost 
before  it  was  again  arrested  by  the  free  application  of  ice ;  it  was  of  a  bright 
arterial  color.     She  became  faint,  and  expired  at  nine  p.m. 

"On  the  day  following  I  made  a  post-mortem  examination  of  the  pai'ts 
afl'ected.     The  parotid,  submaxillary  glands,  and  other  parts,  having  tjeen 

49 


786  ORAL  DISEASES  AND  SURGERY. 

organ  might  be  in  the  grasp  of  red-hot  pincers.  This  neuralgia,  as  I 
hav^e  met  with  it,  has  been  in  the  persons  of  middle-aged  men  :  of  the 
cause  of  it  I  have  no  conception.  Yanzetti,  for  the  cure  of  such  a 
neuralgia,  has  recommended  and  practiced  the  operation  of  section 
of  the  lingual  nerve, — accomplished  by  first  drawing  the  tongue 
forward  and  to  one  side,  and  exposing  the  nerve,  through  incision 
of  the  mucous  membrane  on  the  border  of  the  internal  pterygoid 
muscle.  An  excellent  obtunder  is  found  in  the  combination  sug- 
gested in  the  paragraph  on  Epithelioma.  Lingual  neuralgijB  origi- 
nating in  the  offense  of  jagged  teeth  have  their  cause  too  evident  to 
need  comment. 

Effusions. — The  tongue  is  occasionally  the  seat  of  formidable 
congestions  or  effusions.  I  have  known  an  inflamed  tongue  so 
swell  in  a  single  hour  as  almost  to  prevent  respiration.  The  organ, 
when  enlargement  increases  to  an  extent  which  threatens  suffoca- 
tion, looks  so  vascular  that  one  hesitates  to  use  the  knife.  I  am 
sure,  however,  I  suggest  the  very  best  practice  when  I  say  incise 
fceely, — cut  deeply  from  behind  forward,  on  each  side  of  the  median 
line,  avoiding,  however,  in  the  depth  of  the  cut,  the  ranine  arteries. 
A  wound  thus  made  will  bleed  for  a  time  freely,  even  alarmingly ; 
but  the  common  experience  is  that  such  cuts  soon  close,  and  are 
devoid  of  danger.  Velpeau  has  recommended  the  opening  of  the 
ranine  veins  in  congestion.  Leeches  are  also  applied  direct  to  the 
tongue. 

Erysipelas. — A  formidable  danger  in  the  tongue  is  the  presence 
of  erysipelas :  this  may  be  idiopathic,  but  is  most  frequently  trau- 
matic, operatioGS  about  the  jaws  being,  occasionally,  provocative  of 
this  condition.  The  treatment  of  erysipelas  in  the  tongue  is  the  same 
as  its  treatment  elsewhere.  Iron  and  quiuia,  internally  and  locally, 
should  be  freely  enfployed.    If  this  be  not  found  effective,  then  make 

brought  into  view,  were  found  (on  the  right  side)  so  much  softened,  decom- 
posed, and  mixed  with  coagulated  blood  and  pus,  as  to  be  recognized  with 
difficulty,  and  it  was  impossible  to  trace  from  what  vessel  the  hemorrhage 
proceeded,  such  was  the  destruction  of  the  parts.  On  the  left  side,  the  glands 
were  of  a  greenish  color,  very  much  softened,  and  bathed  in  pus.  A  probe 
passed  readily  by  the  side  of  the  jaw  into  the  mouth.  I  divided  the  trachea 
just  above  the  sternum,  and  dissected  the  larynx  and  tongue  carefully  out. 
The  morbid  state  of  the  tongue  is  shown  in  the  preparation  before  the  society. " 
In  the  discussion  which  ensued,  the  case  was  considered  a  very  remarkable 
one.  The  remarks  had  reference  chiefly  to  the  cause  of  the  disease,  respecting 
which  various  opinions  were  expressed. 


THE   TONGUE  AND   ITS  DISEASES.  787 

incisions.  The  practitioner  is,  however,  never  to  forget  to  extend 
his  observations  over  any  functional  disturbances  which  may  exist. 

Bites  op  Insects. — The  most  severe  and  threatening  glossitis 
ever  met  with  by  the  author  was  the  result  of  the  sting  of  a  wasp 
taken  into  the  mouth  while  eating  blackberries.  The  tongue  in  these 
accidents  is  apt  to  swell  enormously,  but,  happily,  tends  to  a  rapid 
self-cure.  If  seen  immediately,  no  better  application  may  be  employed 
than  the  phenate  of  soda  ;  dilute  ammonia  is  also  a  favorite  prepara- 
tion :  later,  we  can  onlj^  treat  such  an  inflammation  like  any  other  of 
the  sthenic  type.  It  is  well,  however,  to  remember  that  the  swelling 
in  these  cases  is  from  effusion  rather  than  a  congestion  ;  incisions,  if 
necessary,  may  always  be  freely  made.  Iodine,  in  these  instances, 
sometimes  acts  very  happily  ;  paint  the  tongue  thoroughly,  and  hold 
cold  water  in  the  mouth.  If,  unfortunately,  erysipelas  should  super- 
vene, the  iron  and  quinia  combination  is  at  once  to  be  resorted  to.* 
In  these  cases  the  pain  becomes  excessive,  the  parts  may  assume 
a  livid  hue,  and  there  seems  to  be  a  decided  tendency  to  gangrene ; 
particularly  does  this  occur  in  depraved  and  broken-down  persons. 
Free  incisions  are  never  to  be  neglected :  the  degraded  expression  of 
the  erysipelas  in  these  cases  depends  upon  the  separation  of  the 
molecules — if  the  expression  may  be  used — from  their  base  of  sup- 
ply ;  the  incisions,  draining  the  organ,  allow  contraction  of  the  parts, 
and  thus  restore  the  circulatory  relationship. 

In  ulcers  or  tumefactions  of  the  tongue  provoked  by  irritating 
teeth,  it  is  seldom  necessary  to  do  more  than  remove  the  source  of 
offense.  Cases  occur,  however,  where  some  after-treatment  is  de- 
manded, the  provoked  ulcer  being  indolent,  or,  in  some  instances, 
even  semi-gangrenous.  For  all  such  sores,  the  best  wash  that  I  have 
ever  used  is  water,  changed  in  color  to  a  milky  blue  by  the  addition 
of  the  compound  tincture  of  capsicum.  Where  a  part  is  simply 
indurated  and  not  ulcerated,  presenting  no  evident  cause,  it  is  better, 
for  a  time  at  least,  to  leave  the  case  to  nature.  My  own  rule  is, 
never  to  meddle  with  a  non-explainable  induration  except  from  ne- 
cessity. In  all  these  cases  injudicious  meddling  will  be  found  very 
bad  practice. 

Erectile  Tumors. — Of  this  character  of  lingual  tumors  the  author 

*  R. — Tincture  ferri  chloridi,  gij ; 
Quiniae  sulphatis,  gr.  xv  ; 
Tiucturse  cinchonsE,  ^ij  to  ^ss.     M. 
The  author  believes  thai  this  combination,  as  a  local  application,  is  an  ap- 
proach to  a  specific  in  erysipelas. 


788  ORAL  DISEASES  AND   SURGERY. 

has  met  thus  far  with  some  five  cases.  Of  these,  the  most  marked 
was  in  the  person  of  a  babe  nine  months  of  age,  for  whose  relief  an 
operation  was  successfully  performed  at  the  University  clinic.  This 
tumor,  which  was  congenital,  occupied  the  whole  anterior  third  of 
the  tongue,  protruded  from  and  filled  up  the  oral  fissure  to  a  consid- 
erable extent,  was  of  a  dark  red  or  purple  color,  enlarged  very 
much  when  the  child  cried,  was  soft  and  fluctuating,  and  through 
manipulation  could  be  made  temporarily  to  disappear. 

A  mode  of  operation  which  in  two  weeks  resulted  in  a  perfect 
cure,  consisted  in  first  strangulating  the  mass  with  a  double  ligature, 
and,  after  three  days,  effecting  separation  through  the  instrumen- 
tality of  a  wire  ecraseur. 

The  principle  of  the  treatment  of  erectile  tumors  of  the  tongue  is 
the  common  principle  applicable  to  this  class  of  tumors  wherever 
found.     (See  Erectile  Tumors.) 

Fatty  Tumors. — These,  like  the  erectile,  are  uncommon.  A  case 
which  I  once  saw  exhibited  the  tumor  looking  like  a  mass  of  very 
smooth  fat,  encysted  by  the  mucous  membrane:  the  situation  was 
the  inferior  left  surface  of  the  organ.  As  the  patient  would  speak, 
the  tumor  would  bulge  out  over  his  lower  teeth,  presenting  a  most 
unsightly  appearance.  He  was  not  willing  to  submit  to  an  opera- 
tion ;  and  it  was  with  a  feeling  of  disappointment  that  I  found  my- 
self unable  to  follow  the  history  of  the  case. 

Metastatic  Disease. — An  example  herewith  given  explains, 
without  other  remarks,  a  character  of  trouble  rare,  yet  sometimes 
met  with,  upon  the  tongue.  We  may  recognize  in  the  disappearance 
and  reappearance  of  the  various  exanthems  an  explanation  of  the 
condition.  "I  have  been  consulted,"  says  Mr.  Wm.  McClure,  in  a 
paper  read  before  the  Harveian  Society,  "by  a  young  married  lady, 
for  rather  a  curious  afl'ection.  She  informs  me  that  her  tongue 
becomes  occasionally  bestudded  with  small  ulcerations,  and,  after- 
ward, when  these  get  well,  the  palm  of  her  left  hand  becomes  affected 
with  a  sort  of  psoriasis  palmaris.  The  tongue  is  at  present  quite 
well,  but  the  palm  of  her  hand  is  covered  with  the  eruption.  When 
this  gets  better,  however,  she  expects  her  tongue  to  become  again 
the  seat  of  disease,  for  thus  they  have  alternated  for  a  considerable 
time  past, — she  says  about  two  years.  The  chief  reason  for  which 
she  consults  me  at  present,  however,  is  that  she  has  gout  in  one  of 
her  feet.  I  believe  that  the  whole  series  of  her  complaints  depends 
on  some  derangement  of  the  digestive  organs,  though  that  is  not 
made  very  apparent  by  external  symptoms.  I  gave  her  an  alterative 


THE   TONGUE  AND  ITS  DISEASES.  789 

pill,  and  a  tonic  mixture,  combined  with  colchicum  and  an  alkali. 
The  gout  has  already  disappeared,  and  even  the  hand  is  much  im- 
proved. As  soon  as  the  gout  was  got  rid  of,  I  substituted  for  the 
tonic  mixture — in  which,  as  I  have  just  said,  were  wine  of  colchicum 
and  carbonate  of  soda — a  mixture  composed  of  the  extract  of  sarsa- 
parilla  combined  with  the  iodide  of  potassium.  As  a  local  applica- 
tion to  her  hand  I  prescribed  an  ointment  composed  of  pure  iodine, 
iodide  of  potassium,  and  hog's  lard;  but  this  was  found,  upon  trial, 
to  give  her  so  much  pain,  and  produced  so  much  irritation,  that  I 
was  forced  to  abandon  its  use  after  a  few  days'  trial.  For  it  I  sub- 
stituted the  following  ointment,  viz. :  white  oxide  of  mercury  four 
grains,  and  extract  of  conium  a  drachm,  rubbed  up  with  seven 
drachms  of  prepared  hog's  lard.  This  ointment  was  ordered  to  be 
rubbed  into  the  palm  of  her  hand  every  day,  both  morning  and 
evening.  Besides  these  remedies,  local  and  general,  she  took  occa- 
sionally an  alterative  and  aperient  pill,  made  up  of  blue  pill  and  the 
compound  extract  of  colocyuth.  The  consequence  has  been,  after  a 
month's  steady  use  of  the  remedies,  that  the  hand  has  become  quite 
well,  the  skin  being  now,  for  the  first  time  these  two  years,  soft, 
white,  flexible,  smooth,  and  completely  free  from  itching,  heat,  and 
every  unpleasant  appearance  and  feeling.  Nor  has  the  tongue  as 
yet  shown  any  tendency  to  alternate  disease,  as  before  ;  so  that  we 
have  reason  to  hope — the  constitution  having  been  set  to  rights  by 
the  means  employed — the  former  chain  of  morbid  sympathy  between 
the  distant  organs  of  which  we  have  been  speaking,  and  by  which 
a  metastasis  of  the  psoriasis,  from  the  one  to  the  other  alternately, 
took  place  so  often,  for  so  long  a  time,  has  been  at  last  broken  and 
destroyed,  permitting  both  to  remain  in  their  healthy  condition." 

Urticaria,  a  very  common  skin-trouble,  I  have  myself  met  with 
as  having  a  similar  metastatic  relation.  In  this  case  a  wheal  would 
appear  either  upon  the  cheek  or  the  tongue  whenever  ice-cream  was 
eaten. 

Hypertrophy. — This  condition  has  beien  met  with  and  described 
by  various  writers.*     Hypertrophy  may  be  complete,  involving  the 

*  "  A  case  is  related  by  Zacchias,  of  a  male  infant  well  made  except  that  the 
tongue  projected  three  fingers' breadth  from  the  mouth  :  the  child  could  suck, 
and  lived  until  the  age  of  fourteen  months.  Bertholin  mentions  a  case  of 
linguas  portentosa  magnitudo,  where  a  male  child  was  born  with,  the  tongue 
out  of  its  mouth  as  large  as  a  filbert:  as  the  child  grew  its  tongue  enlarged 
to  the  size  of  a  calf's  heart.  A  case  is  recorded  by  Dr.  Humphrey  of  a  child, 
eleven   years   of  age,  whose  tongue  from  the  upper  lip  to  its  tip  measured 


790  ORAL  DISEASES  AND  SURGERY. 

whole  organ,  or  the  enlargement  may  pertain  to  particular  tissues 
alone.  A  case  is  described  bj  Mr.  Paget,  involving  the  muscular 
substances  exclusively,  the  primitive  fasciculi  being  found  to  divide 
in  a  dichotomous  manner.  The  epithelium  is  another  of  the  tissues 
most  frequently  found  affected,  instances  being  on  record  where  this 
structure  has  thickened  so  as  to  resemble  a  coat  of  mail.  Granular 
hypertrophy,  a  condition  of  enlargement  of  the  papillary  structure, 
is  sometimes  seen  in  the  form  of  a  mass  of  warty  excrescences  cover- 
ing the  whole  body  of  the  tongue ;  at  other  times  it  is  confined  to 
some  portions  more  or  less  limited  in  extent. 

The  treatment  of  a  hypertrophied  tongue  must  be  governed  by 
the  circumstances  and  character  of  each  particular  case.  In  epithe- 
lial hypertrophy  the  best  results  seem  to  have  been  secured  through 
the  use  of  arsenic, — from  the  thirtieth  to  the  twentieth  of  a  grain 
being  administered  three  times  a  day,  its  effect  being  carefully  noted. 
Donovan's  solution,  the  liquor  arsenici  et  hydrargyri  hj^driodatis, 
given  in  five-drop  doses,  has  been  highly  commended  ;  also  the  solu- 
tion of  Lugol. 

In  granular  or  papillar}'^  hypertrophy,  the  use  of  chromic  acid  will 
be  found  desirable,  the  various  excrescences  being  touched  daily  with 
the  crystals.  Another  excellent  application  is  the  solution  of  the 
perchloride  of  iron.  Cutting  the  warts  away  in  mass,  by  the  use 
of  a  pair  of  scissors,  may  be  practiced  where  the  parts  are  not  too 
vascular.     Pyroligueous  acid  is  another  favorite  means  of  cure. 

In  a  true  h3q5ertrophy  of  the  organ — prolapsus,  as  it  is  frequently 
miscalled — that  is,  where  the  body  has  enlarged  as  a  result  of  con- 
genital impressions,  medicinal  appliances  are  of  little  service.  This 
disease  is  markedly  one  of  young  life,  commencing  generally  very 
soon  after  birth,  and  progressing  tardily  but  surely  until  death  or 
an  operation  may  give  relief.  Unaccountable  though  it  may  seem, 
hypertrophy  is  confined  almost  exclusively  to  female  children, — this 
sex  being  affected  in  the  proportion  of  five  to  one. 

As  may  be  inferred,  hypertrophy  of  the  tongue  presents  various 
degrees  of  enlargement,  cases  being  on  record  where  the  organ  has 
hung  from  the  mouth,  resting  upon  the  breast.     In  the  cases  of  ele- 


three  and  a  half  inches ;  from  the  under  lip  to  its  tip,  one  and  a  half  inches  ; 
from  the  angle  of  the  mouth  round  the  sides  and  tip  to  the  opposite  angle, 
six  and  a  half  inches.  The  circumference  of  the  widest  part,  which  was  about 
the  middle  of  the  protruded  portion,  measured  six  and  a  half  inches  circular 
measurement." — Holmes. 


THE   TONGUE  AND   ITS  DISEASES.  791 

phantiasis,  the  mucous  membrane  looks  more  like  the  bark  of  a  tree 
than  anything  else,  being  rough,  dry,  and  crusted. 

In  the  treatment  of  hypertrophy  we  consider  the  character  of  the 
trouble  from  the  aspects  of  activity  and  chronicity.  Where  the  first 
of  these  characters  exists,  most  may  be  hoped  for  from  medication ; 
where  the  latter  obtains,  little  may  be  expected  except  from  operation. 

Compression,  recommended  by  Lasser  and  indorsed  by  Professor 
Syme,  it  may  not  be  amiss  to  try  before  proceeding  to  excision ; 
but  the  treatment  will  certainly  be  found  to  have  much  more  of 
failure  than  of  success  in  it.  The  author  lately  had  at  his  clinic  a 
boy  in  whom  congenital  h3^pertrophy  had  enlarged  one  side  of  the 
tongue  to  a  bulk  fully  double  that  of  the  other. 

As  the  opposite  to  hypertrophy,  reference  may  be  made  to  a 
condition  sometimes,  though  unfrequently,  met  with,  of  atrophy.  A 
case  described  by  Dupuytren  found  its  explanation  in  a  post-mortem, 
which  revealed  the  presence  of  hydatids  at  the  base  of  the  cerebellum  ; 
one  of  which,  wedging  itself  into  the  anterior  condyloid  foramen,  had 
compressed  the  lingual  nerve  and  thus  obliterated  its  function. 

Operations  practiced  upon  the  Tongue. — From  surgical  neces- 
sity, or  from  accident,  it  sometimes  becomes  necessary  to  amputate 
a  part  or  even  the  whole  of  the  tongue.  Surprising  as  it  may  seem, 
such  amputations,  even  when  of  the  complete  organ,  interfere  very 
little  with  the  speech,  and  do  not  entirely  obliterate  the  sense  of 
taste.  Mr.  Nunneley,  an  English  surgeon,  lately  exhibited  to  the 
Pathological  Society  of  London  a  patient  from  whom  he  had  re- 
moved the  whole  of  the  organ,  this  being  effected  by  a  submental 
opening,  the  patient,  a  man  aged  thirty-five,  never  having  a  bad 
symptom.  The  disease,  which  had  existed  sixteen  or  eighteen 
months,  became  worse  two  months  before  the  operation,  and,  from 
the  pain  and  difficulty  of  speaking,  the  impossibility  of  mastication, 
and  difficulty  of  deglutition,  was  fast  wearing  the  patient  out.  When 
shown  to  the  society,  the  patient  had  recovered  strength  and  flesh  ; 
indeed,  said  that  he  felt  as  well  as  ever :  he  talked  with  great  dis- 
tinctness, and  swallowed  with  facility. 

A  second  interesting  case  is  reported  by  the  late  James  Syme, 
F.R.S.E.,  Surgeon-in-Ordiuary  to  the  Queen  in  Scotland,  and  Pro- 
fessor of  Clinical  Surgery  in  the  University  of  Edinburgh. 

"About  twelve  months  ago,"  says  Mr.  Syme,  "I  communicated 
a  case  in  which  the  tongue  had  been  completel}^  removed  by  ex- 
cision, on  account  of  extensive  disease  that  threatened  to  prove 
fatal  by  preventing  the  admission  of  nourishment.     This  account 


792  ORAL  DISEASES  AND  SURGERY. 

was  necessarily  limited  to  the  operation  and  its  immediate  effects, 
as  sufficient  time  had  not  elapsed  for  determining  whether  or  not 
the  relief  afforded  would  prove  permanent,  or  how  far  the  powers 
of  deglutition,  articulation,  and  taste  would  be  restored.  After  his 
return  home  to  Manchester,  the  patient  sent  me  favorable  reports 
of  his  progress,  but  certainly  not  such  as  to  convey  any  adequate 
idea  of  the  improvement  that  had  taken  place  since  he  came  under 
my  care.  He  was  then  emaciated  and  bent  down  by  long-continued 
suffering,  unable  to  articulate,  so  as  to  require  a  slate  and  pencil  for 
expressing  his  wishes,  and  swallowing  even  fluids  with  such  extreme 
difficulty  as  to  feel  on  the  point  of  starvation.  My  surprise  may, 
therefore,  be  imagined  when,  on  the  10th  of  September  last,  he  un- 
expectedly made  his  appearance,  erect  and  vigorous,  and,  seeing 
that  I  did  not  recognize  him,  announced  his  name  in  a  loud,  clear 
voice.  The  feeling  thus  excited  was  not  lessened  by  learning  that, 
while  traveling  in  the  Highlands,  he  had  dined  at  tables-cfhole  and 
entered  into  conversation  without  betraying  the  deficiency  under 
which  he  labored.  Yery  much  astonished  by  a  result  so  much 
better  than  could  have  been  anticipated,  I  requested  a  number  of 
my  medical  friends  to  join  me  in  examining  the  state  of  matters. 
Professor  Goodsir  and  Mr.  Nasmyth  having  satisfied  themselves 
that  no  vestige  of  the  tongue  remained,  various  observations  were 
made  with  regard  to  articulation  and  other  functions  of  the  absent 
organ;  and  Mr.  Annandale  afterward  instituted  a  more  particular 
inquiry,  of  which  he  has  given  me  the  following  report: 

"'The  lips  and  jaw-bone,  where  divided,  were  soundly  united 
without  any  deformity.  The  opening  between  the  mouth  and  pharynx 
was  much  diminished  in  size  and  irregular  in  shape  from  contraction 
of  the  fauces  and  soft  palate,  which  were  drawn  downward  and 
forward  more  to  the  right  than  the  left  side,  from  the  mucous  mem- 
brane at  that  part  having  participated  in  the  disease  and  been 
removed  along  with  the  tongue.  Mr.  W.  says  that  he  can  swallow 
as  well  as  ever,  provided  that  the  food  is  either  finely  divided  or 
fluid.  He  is  also  able  to  masticate  solid  substances,  although  diffi- 
culty is  sometimes  experienced  from  their  getting  into  awkward 
parts  of  the  mouth.  In  ordinary  speech  his  words  are  wonderfully 
clear  and  distinct,  and  he  can  sing  without  any  difficulty.  All  the 
vowels  and  words  composed  of  them  are  articulated  perfectly,  and 
also  the  following  consonants :  B,  C,  F,  H,  K,  L,  M,  N,  P,  Q,  R, 
Y,  W.  D  is  pronounced  "  dthe,"  J  "  the,"  G  like  "  sjee,"  "  S"  is  a 
lisp.     His  taste  is  impaired,  but  still   enables  him  to  distinguish 


THE   TONGUE  AND   ITS  DISEASES.  793 

different  articles  and  their  respective  qualities,  as  grouse  from  par- 
tridge, bitters  from  sweets,  good  beer  from  bad  beer,  etc.  He  has 
remarked  that  the  seat  of  sensation  lies  somewhere  in  the  throat, 
since  there  is  no  recognition  of  taste  previous  to  the  act  of  swallow- 
ing ;  and,  in  order  to  ascertain  the  truth  on  this  point  more  pre- 
cisely, the  following  experiments  were  made  : 

"  '  1.  A  strong  solution  of  salt  was  applied  by  means  of  a  camel's-hair 
brush  to  the  fauces,  palate,  floor  of  the  mouth,  lips,  and  inner  surface 
of  the  cheek,  with  the  result  of  something  being  felt  in  the  mouth, 
but  no  idea  formed  as  to  its  nature. 

"  '  2.  About  a  quarter  of  a  teaspoonful  of  finely-powdered  sugar 
was  placed  on  the  floor  of  the  mouth,  and,  having  been  allowed  to 
remain  there  a  few  seconds,  was  then  brought  thoroughly  into  con- 
tact with  every  part  of  the  cavity  without  any  recognition  of  its 
nature  ;  but  when  a  little  water  was  added  and  swallowed,  the  taste 
was  immediately  perceived. 

"  '  3.  The  same  experiment  was  repeated  with  another  substance 
(salt),  and  with  the  same  result.' 

"It  has  long  been  known  that  large  portions  of  the  tongue  may 
be  removed  without  destroying  or  materially  impairing  the  power 
of  articulation ;  but  I  am  not  aware  of  any  case  on  record  in  which 
it  has  remained  so  perfect  after  complete  removal  of  the  organ.*  Of 


*  Complete  extirpation  of  the  tongue  ha?  now  heen  practiced  with  success 
by  a  number  of  surgeons,  among  them  by  Fiddes,  Heath,  Nunneley,  Annan- 
dale,  Rizzoli,  and  Sedillot. 

Excision  of  Tongue. — "  The  removal  of  the  entire  tongue  is  altogether  a 
modern  surgical  operation.  Though,  for  time  out  of  mind,  greater  or  less 
portions  of  the  tongue  have  been  removed  by  cutting  instruments,  escharotics, 
actual  cautery,  or  ligatures,  the  importance  of  the  organ  in  deglutition  and 
articulation,  the  difficulty  of  reaching  its  base,  and  especially  the  fear  of  not 
being  able  to  arrest  the  hemorrhage,  owing  to  the  depth  of  the  wound,  the 
size  of  the  arteries,  and  their  near  origin  from  the  carotids,  have  not  un- 
reasonably deterred  attempts  at  more  than  partial  amputation  of  it.  I  believe 
it  was  Mr.  Syme  who  first  suggested  an  operation  for  its  entire  removal,  and 
performed  it  in  the  presence  of  many  members  of  the  association,  when  its 
meeting  was  held  in  Edinburgh.  Unfortunately,  that  patient,  as  well  as  a 
second,  died  a  few  days  after  the  operation;  and  a  solemn  warning  was  pub- 
lished by  Mr.  Syme,  who  declared  that  the  operation  was  so  serious  that 
further  attempts  were  not  justifiable,  as  no  one  could  recover  from  it.  Subse- 
quently, I  believe,  in  a  third  case,  Mr.  Sj'me  was,  by  a  like  proceeding,  re- 
warded with  success;  and  Mr.  Fiddes,  in  Jamaica,  and  Dr.  G.  Buchanan, 
in  Glasgow,  have  also  succeeded  by  the  jilan  laid  down  by  Mr.  Syme.    How- 


794  OEAL  DISEASES  AND  SURGERY. 

the  facts  above  mentioned,  the  one  that  seems  most  curious  is  the 
connection  between  taste  aud  deglutition;  from  which  it  appears 
that  the  latter  is  essential  for  the  full  perception  of  the  former.  If 
the  pleasure  of  taste  could  be  perfectly  gratified  by  mastication 
without  deglutition,  there  would  be  no  limit  to  the  consumption  of 
food ;  but  the  instinctive  desire  to  swallow  an  agreeable  morsel 
affords  a  check  to  any  such  abuse." 

Mr.  Paget  reports  the  following  case: 

"  On  the  20th  of  February  a  little  girl,  about  three  years  of  age, 
was  brought  into  the  operating  theatre  of  St.  Bartholomew's  Hos- 
pital with  hypertroph}^  aud  prolapsus  of  the  tongue,  which  com- 
menced when  she  was  some  six  months  old.  It  now  protruded 
nearly  two  inches,  and  hung  downward,  completely  filling  the  circle 
of  the  lips  ;  its  end  was  dry,  and  excoriated  with  hardened  epithe- 
lium, a  sort  of  crust  having  formed  of  the  size  of  a  shilling  ;  several 
of  the  papillae  also  were  enlarged,  and  in  places  gave  to  the  tongue 
a  warty  or  granular  appearance.  The  lower  jaw  had  a^lready  begun 
to  be  deformed,  and  expanded  downward  and  outward;  the  teeth 
were  gradually  separating  from  one  another  in  the  mental  portion 
of  the  jaw,  and  there  was  dripping  of  saliva.  An  examination  of 
the  tongue  by  Mr.  Paget  showed  that  the  organ  was  truly  hyper- 
trophied,  and  the  part  not  prolapsed  completel}"  filled  the  cavity  of 
the  mouth. 

"  Chloroform  was  carefully  given  to  the  child,  and  the  chain  of  an 
ecraseur  was  passed  around  the  tongue  within  the  mouth,  the  jaws 
being  kept  open  by  a  metal  gag.  The  chain  was  slowly  drawn 
home,  and  the  prolapsed  and  hypertrophied  portion  was  detached 
with  little  or  no  bleeding. 

ever,  believing  that  the  severity  of  the  operation  depended  farmore  upon  the 
method  of  proceeding  than  upon  the  mere  removal  of  the  tongue  itself,  I 
devised  what  I  hoped  would  prove  to  be  a  less  formidable  one,  and  which 
experience  has  proved  to  be  so.  Up  to  the  present  time  I  have  removed  the 
entire  tongue  nineteen  times,  and  Dr.  Fenwick,  of  Montreal,  has  done  the 
same  operation  once,  without  any  untoward  symptom  following  in  a  single 
instance.  In  most  cases  the  patient  has  not  required  any  after-treatment, 
being  able  to  sit  up  the  following  day,  and  in  ten  days  to  be  considered  well. 
In  the  majority  of  operations  not  a  drachm  of  blood  has  been  lost.  In  two 
cases  only  has  there  been  any  hemorrhage,  and  in  those  not  more  than  half 
an  ounce  of  blood  was  lost.  In  one  a  point  of  hot  wire,  and  in  the  other  a 
ligature,  at  once  arrested  the  bleeding.  The  little  constitutional  disturbance 
which  follows  this  operation  is  surprising  :  indeed,  in  the  majoritj^  of  cases 
there  is  none." — Thomas  Nunneley,  F.E.C.S. 


THE   TONGUE  AND   ITS  DISEASES.  795 

"  On  examination  of  the  piece  remox^ed,  its  structure  was  found  to 
be  similar  to  that  of  the  natural  organ,  both  in  texture  and  color :  it 
was  simply  a  redundancy  of  growth  from  hypertrophy. 

"The  subsequent  progress  of  the  case  was  reported  as  most  satis- 
factory, a  good  recovery  being  recorded." 

Partial  amputations  of  the  tongue  have  been  very  frequent.  Union, 
in  many  of  the  cases,  is  very  rapid  and  perfect.  In  one  case,  that  of 
a  child,  where  a  kind  of  a  flap  operation  was  made,  I  got  reliable 
union  in  a  single  day,  and  had  no  trouble  with  the  case  afterward. 

Amputation  of  the  tongue,  complete  or  partial,  is  practiced  with 
ligature,  knife,  and  ecraseur.  The  author,  from  his  own  experience, 
gives  the  preference  to  the  last  means. 

Operations. — For  a  surgical  study  of  the  tongue,  and  the  opera- 
tions practiced  upon  the  organ,  the  reader  will  turn  to  Plate  XII. 

Subfig.  1,  in  plate,  is  a  front  view  of  the  anatomical  relations  of 
the  parts  about  the  fauces,  as  shown  with  the  mouth  wide  open. 
1,  the  dorsum  of  the  tongue;  2,  3,  the  tonsils;  4,  the  uvula  ;  5,  the 
anterior  half  arch  ;  6,  the  posterior  half  arch,  with  the  tonsil  between 
it  and  5;  T,  the  soft  pabite. 

Subfig.  2  represents  a  side  view  of  a  vertical  section  of  the  mouth 
and  tongue,  showing  the  relations  of  the  vessels  and  nerves  of  the 
tongue.  1,  the  lingual  artery;  2,  its  sublingual  branch, — the  veins 
accompanying  the  arteries  ;  3,  the  hypoglossal  nerve;  4,  the  raniue 
terminations  of  the  lingual  vessels. 

Subfig.  3  represents  the  situation  and  associations  of  a  disease 
compelling  amputation  of  a  section  of  the  tongue.  The  lines,  1,  2, 
3,  form  a  Y,  which  is  to  cil"cumscribe  the  growth  ;  it  should,  how- 
ever, have  been  placed  much  farther  back. 

Subfig.  4  exhibits  the  operation  of  excising  the  tongue,  as  prac- 
ticed with  scissors.  When  the  knife  is  used,  the  sections  are 
similarly  made.  If,  in  such  an  operation,  the  hemorrhage  is  threat- 
ening, it  is  better  to  ligate  quickly  the  vessels  of  one  side  before 
making  the  section  of  the  o|^her  ;  this  suggestion,  however,  only 
holds  good  when  the  bleeding  orifices  are  freely  exposed  and  can 
be  reached  without  effort  or  difficulty. 

Subfig.  5  shows  the  preceding  operation  completed,  and  the  flaps 
united  by  ligatures.  1,  2,  represent  the  sutures:  wire  pins  or 
waxed  silk  may  be  used.  Let  them  be  left  in  only  long  enough  to 
secure  the  union  ;  this,  if  no  undue  inflammation  supervenes,  will 
be  accomplished  in  from  twenty-four  to  forty-eight  hours. 


796  ORAL  DISEASES  AND   SURGERY. 

Subfig.  6  is  the  lingua  vitula,  or  lingual  hypertrophy.  The  par- 
ticular case  here  represented  was  a  patient  of  Dr.  Harris,  of  Phila- 
delphia, and  was  the  first  operation  performed  in  the  United  States. 
The  case  is  thus  described  by  Prof.  Smith  in  his  System  of  Surgery  : 

"  The  patient,  aged  nineteen,  had  the  tongue  enlarged  at  birth. 
A  short  time  previous  to  the  operation  it  projected  beyond  the  upper 
incisors  at  least  three  inches.  Its  circumference  was  six  inches,  and 
its  vertical  thickness  one  inch  and  a  half;  it  filled  up  the  jaws  so 
completely  that  it  was  necessary  to  have  his  food  cut  iato  small 
pieces  and  introduced  at  the  side  of  the  tongue." 

The  operation  practiced  by  Dr.  Harris  was  accomplished  as  fol- 
lows: "The  tongue  being  elevated,  a  strong  ligature  was  passed 
through  its  top  so  as  to  control  its  movements.  The  under  surface 
was  then  dissected  from  the  floor  of  the  mouth  about  three-fourths 
of  an  inch  behind  the  anterior  part  of  the  jaw,  and  a  strong,  straight 
bistoury  introduced  into  the  organ  at  a  point  where  the  dissection 
terminated,  whence  it  was  pushed  through  between  the  median  line 
and  the  left  rauine  artery,  and,  being  drawn  laterally  and  forward, 
was  made  to  cut  a  flap,  w^hich  terminated  near  the  first  bicuspid 
tooth.  The  left  ranine  artery  being  then  secured  with  a  ligature, 
the  bistoury  was  again  introduced  in  a  corresponding  position  on 
the  right  side,  and  the  opposite,  or  right  flap,  made  in  a  similar 
manner.  The  artery  of  this  side  being  now  secured,  and  the  space 
intervening,  or  central  portion,  divided  by  strong  scissors,  the  in- 
cisions or  flaps  resembled  the  letter  Y,  and,  being  approximated  by 
these  interrupted  sutures,  made  a  pointed,  well-formed  tongue  of 
the  ordinary  length.  A  year  subsequently  the  patient  articulated 
distinctly,  and  was  relieved  of  all  deformity." 

Fig.  243. — Amputation  by  Strangulatiox. 


In  another  case,  somewhat  similar  to  this,  under  the  care  of  the 
same  surgeon,  a  ligature  was  applied  to  the  enlarged  portion,  iu 


THE   TOJSIGUE  AND   ITS  DISEASES.  797 

order  to  cause  it  to  slough  oflf;  but  the  irritation,  Prof.  Smith  informs 
us,  was  so  great  that  Dr.  Harris  found  himself  subsequently  com- 
pelled to  amputate  the  end  of  the  tongue  with  a  catlin.  In  this 
patient  the  organ  protruded  four  inches  ;  its  circumference  was  over 
six  inches,  and  its  vertical  thickness  nearly  two  inches. 

Fig.  243k  represents  a  condition  of  resisting  ulcer  (met  with  quite 
frequently  by  every  practicing  surgeon),  together  with  a  manner  of 
treatment  by  strangulation.  With  such  ulcers  and  such  manner  of 
treatment  the  author  has  had  quite  a  large  experience,  but,  as  before 

remarked,  he  gives  the  preference  to  the  ecraseur. 

.  .  Fig   244 

A  mode  of  using  the  ligature,  more  convenient 

than  that  exhibited  in  the  diagram,  and  quite 
as  effectual,  consists  in  the  passage  of  the 
double  thread,  exactly  as  is  represented  in  this 
case  by  the  threads  occupying  the  middle  posi- 
tion ;  separating  this  double  ligature,  it  may  be 
made  to  circumscribe  any  portion  of  the  tongue 
simply  by  the  passage  of  pins :  as,  for  example, 
if  in  the  places  of  the  first  and  second  threads, 
as  shown,  pins  were  placed,  it  must  be  seen  that, 
by  separating  the  double  middle  ligatures  and 
casting  them  back  of  the  pins,  the  part  included 
would  be  precisely  the  same  as  found  here  with 
the  six  ligatures.  By  such  use  of  the  double  ligatures  the  author 
has  amputated  full  half  the  tongue  twice  within  four  months.  Such 
a  mode  of  employing  the  double  ligature,  not  alone  for  the  tongue, 
but  in  any  other  situation,  is  shown  in  Fig.  244. 

The  Eoraseur. — Fig.  245  exhibits  the  ecraseur  of  the  inventor 
of  the  instrument,  the  French  surgeon  M.  Chassaignac.  Of  the 
two  forms  shown,  the  one  to  the  right  will  be  found  most  to  com- 
mend itself,  the  direction  of  the  chain  being  best  conti'olled  by  it. 
To  use  the  ecraseur,  it  is  simply  necessary  to  arrange  the  chain  back 
of  the  part  to  be  amputated,  the  handle  being  next  slowly  turned, 
whereupon  the  chain,  little  by  little,  is  retracted,  until  finally — the 
time  should  seldom  be  less  than  half  an  hour — the  portion  of  tissue 
drops  off",  without,  quite  as  likely  as  not,  the  loss  of  a  single  drop 
of  blood  ;  as  exhibited  in  the  case  of  an  amputation  of  the  tongue, 
performed  at  a  recent  clinic  by  the  author  before  his  class,  where 
the  operation  was  strictly  devoid  of  hemorrhage. 

As  a  substitute  for  the  chain  of  the  Chassaignac  instrument,  a 
common  annealed  wire  is  used  by  many  with  the  most  complete 


798 


ORAL  DISEASES  AND  SURGERY. 


success.  The  use  of  such  a  wire  is  highly  commended  b\^  M.  Maison- 
neuve,  of  Paris,  who  has  published  a  memoir  on  what  he  terms  the 


Fig.  215. — Chassaignac's  Eckaseur. 


Fig.  246. 


*' ligature  extemporanee.^^  Fig.  246  exhibits  this  ecraseur,  and  the 
mode  of  its  application.  A  screw  like  that  of  Graefe's  serre-uceud, 
or  any  other  convenient  means,  may  be  emplo3^ed  to  tighten  the 
wire.  A  very  convenient  instrument  of  such  character  is  furnished 
at  a  trifling  price  b}^  Mr.  Kolbe,  of  Pliiladelphia,  and  may  be  procured 
of  most  surgical  cutlers.  With  such  form  of  ecraseur,  the  author 
has  succeeded  in  amputating  without  trouble  fully  two-thirds  of  the 
tongue. 


Amputation  of  the  tongue  in  full,  an  operation  now  attracting 
considerable  attention,  is  variously  practiced.  A  mode  known  as 
that  of  Regnoli,  shown  in  Fig.  247,  consists  in  opening  into  the 
oral  cavity  from  the  neck,  and,  by  means  of  a  loop  in  the  tip,  drawing 
the  organ  downward.  To  open  into  the  cavity  by  this  plan,  the 
operator  commences  by  making  a  curvilinear  incision  corresponding 
to  the  arch  of  the  jaw,  extending  nearly  from  angle  to  angle.  Joining 
this  first  incision  is  a  second  of  vertical  direction,  extending  to  the 


THE   TONGUE  AND   ITS  DISEASES. 


799 


hyoid  bone.  The  flaps  are  next  to  be  reflected,  and,  after  incising  the 
lingual  muscles  from  the  bone,  the  tongue  is  caught  by  the  tip  and 
drawn  out  of  the  mouth.  Complete  control  of  the  organ  being  thus 
secured,  the  knife  or  ecraseur  is  employed  to  make  the  separation. 


Fig.  247. — Kegnoli's  Operation. 


Fig.  248. — Syme's  Operation. 


A  second  manner  of  operation  is  that  which  was  practiced  by  Mr. 
Syme.  This  is  shown  in  Fig.  248,  and  is  as  follows.  A  first  inci- 
sion divides  the  lower  lip  in  its  exact  median  line,  being  carried  down 
to  the  hyoid  bone.  Next  the  bone,  by  means  of  a  saw,  is  separated 
at  the  symphysis;  this  may  or  may  not  necessitate  the  removal  of 
the  two  front  teeth.  Placing  the  fioger  as  a  guide  beneath  the 
tongue,  the  surgeon  next  incises  the  mucous  membrane,  together 
w^ith  the  muscular  attachments.  At  this  stage  attention  may  be 
given  to  the  hemorrhage,  or  the  tongue,  as  shown,  may  be  drawn 
forward  and  the  amputation  completed  by  the  ecraseur. 

Statistics  favor  the  Regnoli  operation  rather  than  that  of  Mr, 
Syme,  the  section  of  the  jaw  in  the  latter  complicating  to  a  marked 
extent  the  process  of  cure. 

Still  another  operation,  practiced  by  Mr.  Nunneley,  of  Leeds, 
has  yielded  a  success  most  satisfactory,  since  of  nineteen  cases  in 
which  this  surgeon  has  operated,  removing  the  whole  or  a  large  por- 
tion of  the  tongue,  every  one  resulted  in  recovery.  The  operation, 
as  practiced  by  Mr.  Nunneley,  consists  in  a  slight  incision,  a  punc- 
ture, indeed,  made  in  the  exact  middle  line  of  the  throat, — a  little 
nearer  the  base  of  the  jaw  than  the  hyoid  bone,  the  bistoury  being 
passed  upward  until  it  emerges  at  the  frtenum ;  through  this  wound 


800  ORAL  DISEASES  AND   SURGERY. 

is  now  drawn  up  the  chain  of  the  ecraseur,  the  loop  being  cast  about 
the  base  of  the  tongue.  Next,  with  a  volsella,  or  by  any  other  con- 
venient means,  the  organ  is  pulled  outward  and  upward.  To  control 
and  secure  the  loop  of  the  chain  about  the  base,  two  strong  curved 
pins  are  passed  from  below,  through  the  tongue,  to  the  base ;  the 
loop  thus  controlled,  the  ablation  is  made  as  in  the  previous  cases. 

A  fourth  process  is  that  practiced  by  Mr.  Paget.  Separating 
first  the  general  attachments  of  the  genio-hyo-glgssal  muscles,  this 
surgeon  dissects  along  the  floor  of  the  mouth,  thus  liberating  the 
tongue,  whereupon  the  organ  is  caught,  drawn  forward,  and  removed 
with  the  ecraseur. 

In  limited  ablations,  the  surgeon,  not  having  at  command  the 
ecraseur,  may  use  with  satisfaction  the  ligature  as  described  a  page 
back.  A  point  of  importance,  however,  to  consider  in  the  use  of 
this  means,  is  the  danger  of  cutting  the  ligature  out ;  it  is  really  a  nice 
point  to  draw  tight  enough,  yet  not  too  tight.  I  have  seen  a  ligature 
cut  through  a  tongue  almost  with  the  facility  of  a  knife,  compli- 
cating matters  most  seriously  by  the  hemorrhage  which  followed. 
Another  matter  is  correspondence  in  size  of  the  ligature  with  the 
needle  used.  A  needle,  larger  than  the  thread  which  is  to  occupy 
the  line  of  its  passage,  will  not  unfrequently  have  its  use  associated 
with  an  oozing  of  blood,  so  persistent  as  to  compel  the  repetition  of 
an  operation. 

In  the  use  of  the  ecraseur  the  surgeon  will  also  not  unfrequently 
find  himself  confronted  by  hemorrhage,  and  particularly  may  such  a 
result  be  anticipated  where  abundance  of  time  has  not  been  allowed 
for  the  ablation :  the  rule  with  this  instrument  should  be,  "  never 
make  haste." 

Shock,  inflammatory  perversions,  and  septsemia,  are  the  dangers 
associated  with  operations  upon  the  tongue,  and  which  the  prudent 
surgeon  will  guard  against  by  every  precaution  known  to  the 
science.  After  an  operation  of  magnitude  upon  this  organ,  I  believe 
it  is  always  prophylactic  practice  to  prescribe  veratrum  viride, 
bromide  of  potassium,  and  morphia;  while  as  a  local  detergent, 
nothing  better  can  be  used  than  the  phenate  of  soda,  or,  if  inflam- 
mation supervenes,  this  conjoined  with  the  fluid  extract  of  hamamelis 
Yirginicus. 

ToNGUE-TiE. — The  condition  denominated  tongue-tie  is  frequently 
met  with  in  young  children,  and,  indeed,  occasionally  in  the  adult. 
Tongue-tie  is  simply  a  shortening  or  curtailment  of  the  anterior 


THE   TONGUE  AND   ITS  DISEASES.  801 

mucous  frseuum.  A  tongue  that  cannot  be  projected  beyond  the 
teeth,  and  in  the  attempt  at  projection  has  its  tip  drawn  downward, 
is  tied,  and  a  tongue  so  tied  cannot  perform  its  various  offices  com- 
fortably and  naturally.  Upon  examining  the  mouth  of  a  child  thus 
afflicted,  the  tip  of  the  tongue  will  not  unfrequently  be  found  fixed 
to  the  floor  of  the  mouth,  incapable,  indeed,  of  any  movement. 
These,  however,  are  extreme  cases,  the  usual  condition  being  simply 
curtailment  of  na.tural  motion. 

Tongue-tie  is  of  two  kinds,  adventitious  and  congenital.  Of  the 
first,  that  arising  from  ulceration  is  the  most  common.  A  person 
having  a  bad  ulcer  under  the  tongue,  particularly  if  on  the  side  of 
the  fraenum,  is  almost  sure  to  have  this  fold  shortened  as  the  result 
of  cicatrization. 

A  second  expression  of  this  first  form  is  one  described  by  Prof. 
Dewees,  exceedingly  rare,  1  imagine,  but  worthy  of  note. 

"There  is  found  attached,"  says  Dr.  Dewees,  "to  the  fraenum  of 
the  tongues  of  new-born  children  a  nearly  transparent,  whitish 
membrane,  which  pursues  the  natural  frrenum  through  its  whole 
course,  continues  beyond  the  point  where  the  fraenum  stops,  and 
terminates  near  the  extremity  of  the  tongue  itself;  so  that  the  tongue 
is  tied  down,  as  it  were,  to  its  proper  bed. 

"  In  consequence  of  this  disposition  of  the  frasnum,  the  child 
cannot  elevate  the  tongue  or  protrude  it  beyond  the  lips,  and  in 
attempts  to  suck  cannot  apply  it  with  sufficient  force  or  certainty 
to  the  nipple  to  make  a  complete  exhaustion;  therefore  it  sucks 
but  imperfectly;  and  this  is  accompanied  by  a  clucking  kind  of 
noise.  Whenever  this  is  observed,  the  mouth  should  be  examined, 
and  it  will  almost  always  be  found  in  the  situation  just  described  ; 
but  not  necessarily,  as  there  may  be  clucking  without  this  mem 
brane  ;  but  this  membrane,  we  believe,  is  never  without  the  clucking. 

"This  membrane  is  easily  discovered  by  provoking  the  child  to 
cry,  or  by  elevating  the  point  of  the  tongue  by  the  extremity  of  the 
little  finger.  In  making  the  attempt  to  raise  the  tongue,  the  child 
is  almost  sure  to  cry  ;  and  then  this  membrane  is  readily  discovered, 
as  it  is  now  fully  upon  the  stretch. 

"  This  defect  is  easily  remedied.  It  should  be  done  in  the  follow- 
ing manner.  Let  the  child  be  laid  across  the  lap  of  the  nurse,  with 
its  face  toward  a  proper  light,  and  the  operator  stand  behind  the 
head,  so  that  he  does  not  intercept  the  light.  The  chin  of  the  child 
must  be  genth^  depressed  by  the  forefinger  of  the  nurse.  When  the 
chin  is  thus  depressed,  the  little  finger  of  the  left  hand  of  the  ope-r- 

50 


802  ORAL  DISEASES  AND  SUBGERY. 

ator  must  be  insinuated  between  the  side  of  the  tongue,  near  its  tip, 
and  the  inner  corresponding  portion  of  the  jaw,  until  it  can  lift  up 
the  point  of  the  tongue;  which  being  done,  the  membrane  is  imme- 
diately brought  into  view,  and  upon  the  stretch  ;  or,  should  the  child 
now  begin  to  cry,  as  it  almost  always  does,  tjae  o})erator  can  easilj' 
place  his  finger  under  the  tongue,  and  keep  this  false  frsenum  tense, 
while,  by  a  single  stroke  directly  across  it  by  a  sharp  gum  lancet, 
he  divides  it  to  the  true  fraenum  :  the  operatioi\  is  then  finished. 
We  have  never  known  it  necessary  to  repeat  this  operation.  The 
incision  through  the  membrane  never  yields  more  than  a  small  drop 
of  blood  ;  no  hemorrhage  can  ensue,  as  this  tissue  is  but  very  slightly 
vascular." 

A  third  of  the  adventitious  forms,  occurring  in  the  adult,  is  the 
result  of  induration  of  the  fraenum.  This  is  occasionally  vene- 
real in  character,  or  it  may  be  cancerous.  In  these  cases  the 
baud  gradually  thickens  until  the  motion  of  the  tongue  is  markedly 
impaired.  The  cancerous  is  distinguished  in  its  incipiency  from 
the  venereal  disease  by  the  greater  pain  associated  with  the  move- 
ments of  the  parts:  in  the  first,  the  pain  is  acute  and  sharp ;  in  the 
second,  it  is  soreness  rather  than  pain.  If  the  induration  is  malig- 
nant, the  parts  may  be  excised,  but  the  hope  of  cure  is  very  slight ; 
if  venereal,  we  pursue  the  specific  treatment  conjoined  with  such 
general  and  local  combinations  as  may  seem  demanded  by  the 
circ\jmstances  of  the  case.  Donovan's  solution,  given  in  five-drop 
doses,  is  quite  reliable.  The  practitioner  is  to  avoid  over-irritation 
of  the  fraenum. 

Congenital  tongue-tie  is  quickly  appreciated  by  lifting  the  tip  of 
the  organ.  These  cases  differ  very  much,  the  fraenum,  at  times, 
being  observed  to  run  as  in  the  normal  course,  except  that  it  is  much 
shortened.  In  other  instances  the  fold  passes  forward  almost  to 
the  apex.  This  fold  may  be  free  or  tight.  If  the  former,  it  forms  a 
septum  between  the  lateral  aspects  of  the  floor  of  the  mouth,  but  is 
not  otherwise  inconvenient;  if  the  latter,  it  ties  the  tongue  more  or 
less  closely. 

The  relief  of  a  congenital  tie  consists  in  nicking  or  cutting  the 
contracted  fraenum.  This  operation,  although  of  the  simplest  nature, 
requires  to  be  performed  with  some  care.  A  fraenum  too  freely  cut 
will  permit  of  the  tongue  being  pulled  quite  far  back  into  the  fauces ; 
cases  are  on  record  where  sulfocation  has  nearly  resulted  from 
such  an  accident.  Again,  it  must  not  be  forgotten  that  the  ranine 
vessels  inosculate  just  in  front  of  the  fraenum  on  the  under  surface 


i 


THE   TONGUE  AND   ITS  DISEASES.  803 

of  the  tongue,  and  might  veiy  easily  be  divided  in  an  operation. 
Many  children  have  lost  their  lives  from  such  an  accident. 

A  proper  operation  consists  in  making  a  simple  nick  midway  be- 
tween the  tongue  and  the  floor  of  the  mouth  :  a  rupture  of  the  part 
thus  effected,  the  motions  of  the  tongue  will  quickly  secure  all  the 
latitude  required.  Should  an  operation,  unfortunately,  open  a  vessel, 
the  best  practice  would  be  to  secure  it  with  a  ligature  ;  but  this 
is  not  always  easy  of  accomplishment,  the  artery  retracting  within 
its  loose  sheath.  An  instrument  devised  by  M.  Petit  to  control 
such  a  hemorrhage  consists  of  a  piece  of  ivory,  cut  fork-shape, — 
the  prongs,  of  which  there  are  two,  passing  on  either  side  of  the 
frsenum,  the  short  handle  resting  against  the  inside  of  the  jaw.  To 
apply  this  instrument,  introduce  against  the  bleeding  vessel  a  tuft 
of  lint  saturated  with  alum-water  or  other  astringent,  then  place 
the  fork  about  it,  and  secure  it  by  pressing  it  down  with  the  tongue, 
over  and  around  which,  and  the  jaw,  a  roller  is  to  be  thrown.  A 
much  better  means,  however,  would  be  the  use  of  the  thimble  com- 
press, referred  to  on  page  310.  Guersent,  in  his  "  Surgical  Diseases 
of  Children,"  recommends  the  serre-fine,  or  the  retention,  for  a  time, 
of  agaric  against  the  part.  Another  means,  where  the  wounded 
vessel  is  not  too  far  retracted  to  be  caught,  would  be  the  employ- 
ment of  torsion.  The  use  of  nitrate  of  silver  or  of  Monsel's  salts 
in  these  cases  cannot  be  too  forcibly  discountenanced,  the  injury 
done  by  them  to  the  tender  parts  making  secondary  hemorrhage 
almost  a  necessity. 

Swallowing  ttje  tongue,  as  it  is  called,  is  a  disagreeable  accident, 
and  may  occur  without  section  of  the  fraenum.  Dr.  Dewees  mentions 
one  case  in  which  a  child  became  choked  several  times  a  day  from 
such  a  recession.  It  was  always,  however,  relieved  by  the  nurse, 
who  would  press  the  organ  down  with  the  handle  of  a  spoon  and 
then  draw  it  forward. 

To  operate  for  tongue-tie,  it  is  best  to  place  the  body  of  the  infant 
upon  the  lap  of  the  nurse,  the  head  being  received  upon  or  between 
the  knees  of  the  surgeon ;  the  tip  of  the  tongue  is  then  raised,  and 
the  cut,  or  nick,  made  with  a  pair  of  curved  scissors. 


CHAPTER   XXXYIII. 


TUMORS. 


In  the  following-  pages  the  author  proposes,  after  much  reflec- 
tion, and  after  a  thorough  study  of  the  views  and  observations  of 
the  latest  writers,  German,  English,  and  American,  to  present  to 
his  readers  the  subject  of  tumors,  precisely  as  in  his  own  clinical 
service  he  meets  with,  classifies,  and  treats  such  conditions.  He 
disregards  to  a  certain  extent  the  classification  of  others,  because 
that  which  is  here  adopted  seems  to  him  most  rationally,  philoso- 
phically, and  naturally  to  introduce  and  evolve  the  subject.  The 
text  of  the  chapter  is  to  be  understood  as  being  of  a  strictly  clinical 
signification.  In  the  foot-notes  —  which,  however,  a  student  is 
advised  not  to  read  until  he  has  mastered  the  practical  signification 
of  the  text,  thus  guarding  himself  against  confusion — will  be  found 
the  views  and  expressions  of  pathological  histology. 

Such  classification  of  the  tumors  as  is  here  offered,  it  is  be- 
lieved, opens  the  subject  to  the  ordinary  practitioner  with  all 
necessary  practical  clearness,  while  it  must  be  seen  to  limit  in 
no  way  the  examinations  and  inquiries  of  the  most  inquisitive 
microscopist. 

The  surgical  expression  "  tumor"  is  a  terra  having  its  origin  in 
the  Latin  verb  tumeo,  to  "swell,"  and,  therefore,  necessarily  applies 
to  any  unnatural  enlargement  of  a  part,  no  matter  upon  what  it 
may  depend  or  from  what  cause  it  may  arise. 

A  tumor  is  a  swelling  which  varies  in  its  nature  from  that  which 
has  a  signification  in  some  accidental  and,  it  may  be,  evanescent 
functional  derangement — as,  for  example,  a  foot  oedematous  from 
exhausting  exercise,  an  abdomen  swollen  from  accumulated  flatus, 
a  duct  expanded  from  obstruction  of  its  outlet — to  that  character  of 
an  outgrowth  which  is  without  explanation  in  itself  or  in  any  phys- 
iological or  anatomical  association, — a  something  which,  by  exclu- 
sion, must  be  classified  as  an  expression  of  constitutional  meaning 
(804) 


J 


TUMORS.  805 

and  signification, — a  vice.     (In  the  foot-note  will  be  found  the  argu- 
ment of  Billroth  against  this  premise.*) 

*  "  When  Ji  part  of  the  body  is  abnormally  enlarged,  we  make  a  distinction 
as  to  whether  the  enlargement  is  caused  by  an  abnormal  increase  of  the  volume 
of  the  difterent  elements  (simple  hypertrophy),  or  by  a  formation  of  new  ele. 
ments  which  are  deposited  between  the  old  ones.  The  new  formation  may  be 
analogous  to  the  matrix  or  mother  tissue  (homoplastic),  or  not  (heteroplastic). 
The  homoplastic  new  formation  proceeds  either  from  simple  division  of  the 
existing  elements  (thus,  a  cartilage  cell  by  segmentation  forms  two,  then  four, 
cartilage  cells:  then  it  is  called  hyperplastic,  numerical  hypertrophy),  or  at 
first  apparently  indifferent,  small,  round  cells  form  from  the  existing  cellular 
elements,  and  from  these  a  tissue  analogous  to  the  matrix  is  developed, — 
homoplastic  new  formation  in  strict  sense.  Heteroplastic  new  formation 
always  begins  with  the  development  of  primary  cell  tissue,  so-called  indilfer- 
ent  formative  cells  (granulation  stage  of  tumors — Virchow),  and  from  these 
develops  the  tissue  heterologous  to  the  matrix,  as  cartilage  in  the  testicle, 
epidermis  in  the  brain,  etc. 

"This  nomenclature  proposed  by  Virchow  seemed  perfectly  suitable  and 
natural  in  a  purely  anatomical  point  of  view  ;  and  I  can  still  accept  it,  if  the 
term  heteroplastic  be  limited,  and  if  we  dismiss  the  idea  that  homoplastic 
is  synonymous  with  benignant,  and  heteroplastic  with  malignant.  We  must 
here  add  that  there  is  everj^  probability  that  wandering  cells  escaping  from 
vessels  very  materially  aid  in  the  formation  of  tumors,  at  least  in  the  forma- 
tion of  tumors  of  the  connective-tissue  series.  But,  apart  from  this,  we 
should  err  if  we  supposed  that  in  the  above  nomenclature  all  cases  of  new 
formations,  even  considered  in  a  purely  anatomical  point  of  view,  could  be 
easily  labeled,  ready  to  be  placed  away  in  a  museum.  The  simple  numerical 
hypertrophies  and  hyperplasise,  although  in  some  cases  difficult  to  distinguish, 
are  at  least  theoretically  separable;  the  same  way  with  those  new  formations 
which  do  not  consist  of  similar,  well-formed  tissue  elements.  A  connective- 
tissue  tumor  occurring  in  connective  tissue  would  always  be  termed  homo- 
plastic; found  in  bone,  brain,  or  the  liver,  it  would  be  heteroplastic,  etc. 
Well-developed  alveolar  cancerous  tissue  also  usually  presents  no  difficulty 
of  classification,  for  it  does  not  normally  occur  in  any  part  of  the  body  ;  it  is 
everywhere  heterologous.  But  what  shall  we  say  of  the  neoplasias  which 
have  no  fully-developed  or  entirely  abnormal  form  of  tissue,  but  consist  of 
elements  that  cannot  be  found  elsewhere  ?  What  becomes  of  them  ?  or  can 
anytliing  develop  from  them  (indifferent  formative  cells,  primary  cell  tissue, 
granulation  tumors)  ?  and  where  shall  we  place  those  neoplasiis  which  are  not 
completed  tissue,  but  are  evidently  normal  tissue  in  the  stage  of  development? 
According  to  the  above  definition  of  heterology  and  homology,  inflammatory 
new  formation  is  at  first  heterologous  everywhere  ;  but  the  connective-tissue 
cicatrix  developing  from  it  subsequently  becomes  a  homologous  neoplasia  in 
connective  tissue ;  in  muscles  it  almost  always  remains  heterologous ;  the 
same  way  in  the  brain  and  in  the  bones,  if  it  does  not  ossify.  You  see  that 
here  parts  which  from  their  nature  and  mode  of  origin  naturally  belong 


806  ORAL  DISEASES  AND  SURGERY. 

The  study  of  tumors  is  to  be  pursued  from  a  twofold  stand-point, 
clinical  and  histological.  The  first  has  to  do  with  that  classification 
of  the  conditions  which  directs  the  practice  demanded.  The  second 
analyzes  under  the  microscope  the  histogeny  of  a  growth,  and 
describes  the  expressions  of  its  anatomy. 

Clinically,  experience  would  seem  fairly  to  demonstrate  that  a 
rational  primary  distinction  of  the  tumors  is  found  in  separating 
them  into  two  classes.  One  class  embraces  every  tumor  that  pos- 
sesses a  local  self-explanation,  as,  for  example,  sebaceous  tumors, 
ranulfe,  hernise,  hydrocele.  The  other  class  comprises  all  that 
remainder,  the  explanation  of  which  has  to  be  sought  outside  of  a 
local  condition ;  examples  in  this  latter  direction  being  recognized  in 
the  nodes  of  syphilis,  the  degenerating  glandular  enlargements  of 
tuberculosis,  the  multitudinous  expressions  of  cancer. 

All  tumors  of  the  first  class  are,  m  themselves,  of  a  necessity, 
benign.  All  tumors  of  the  second  class  are  to  be  viewed,  not  in 
themselves,  but  in  the  dyscrasia  of  which  they  are  simply  ex- 
pressions. 

Tumors  of  the  first  class,  having  only  a  local  signification,  de- 
mand only  a  local  treatment ;  tumors  of  the  second  class,  having, 
save  in  the  accident  of  the  habitat,  no  local  signification,  but  being 
of  constitutional  relation,  are  capable  of  rational  treatment  only 
through  remedy  directed  to  the  vice  as  it  exists  in  the  system  at 
large. 

Tumors  of  the  first  class  may  be  termed  homologous,  indicating 


together  are  sundered  by  the  anatomical  nomenclature.  But  let  us  leave 
inflammatory  neoplasia  out  of  the  question.  Every  tumor  resulting  from 
indifl:erent  formative  cells  must  exhibit  a  series  of  stages  of  development,  if 
the  cells  are  transformed  to  one  or  several  sorts  of  tissue. 

"  Wherever  they  are  grouped  together,  indifferent  formative  cells  are 
heterologous  ;  if  a  neoplasia  shows  only  such  elements,  we  will  let  it  pass  for 
heterologous  ;  but  if  it  appears  that  a  number  of  these  cells  have  been  trans- 
formed into  spindle-cells,  the  question  arises,  where  does  this  neoplasia 
belong  ?  Spindle-cells  collected  in  groups  are  heteroplastic  in  all  parts  of  the 
body ;  but  these  cell?  occur  in  fcetal  connective  tissue,  fcetal  muscles,  and 
fcetal  nerves.  "What  would  finally  become  of  the  spindle-cells  of  this  tumor  ? 
If  found  in  muscles,  should  not  this  tumor  still  be  called  homologous?  On 
this  point  we  can  only  decide  arbitrarily.  You  may  look  at  it  from  different 
points  of  view.  Now,  what  shall  we  do  with  tumors  which  contain  the  most 
different  complete  and  incomplete  tissues?  I  will  stop  here,  to  avoid  making 
you  skeptical:  it  is  my  duty  to  help  you  learn,  not  to  throw  obstacles  in  your 
way. ' ' — Billroth. 


«  TUMORS.  807 

by  this  term,  not  likeness  to  associated  tissue  as  exhibited  by  some 
of  the' neoplasias,  but  that  a  tumor  is  part  and  parcel  of  the  location 
in  which  it  exists. 

Tumors  of  the  second  class  may  be  distinguished  as  heterologous, 
indicating  simply  neoplasia,  no  matter  what  the  likeness,  a  some- 
thing which  is  strictly  foreign  to  any  local  expression  of  the  pa7't  in 
which  it  is  found* 

*  "  All  new  formations,  not  hyperplastic,  contain  in  themselves  a  qualitative 
departure  from  the  normal  processes  of  development  and  growth.  It  there- 
fore appears  difficvilt,  at  the  first  view,  to  place  them  upon  a  physiological 
basis.  There  are,  however,  not  so  much  actually  existing,  as  much  more 
artificially  produced  difiiculties,  which  stand  in  our  way;  above  all,  a  trans- 
mitted custom  of  regarding  the  deviating  evil  as  a  hspov,  something  foreign 
introduced  into  the  organism,  of  ascribing  it  to  a  parasitic  existence,  even  a 
kind  of  personality.  This  view,  from  which  the  term  'heteroplasia'  has 
arisen,  has  a  certain  justification :  1st.  In  the  pr'esence  of  those  new  forma- 
tions which  are  caused  by  a  definite  poison  introduced  into  the  body,  and 
conformedly  present  themselves  in  the  most  various  organs  in  the  same 
manner,  thus  in  syphilis,  tuberculosis,  typhus  abdominalis.  2d.  In  the  sense 
that  every  organ  has  its  own  peculiar  new  formations,  which  always  recur 
in  the  same  forms  with  slight  modifications,  so  that  we,  if  they  have  pro- 
gressed up  to  a  certain  point,  may  thereupon  base  a  sure  diagnosis  and  pro- 
gress. It  is,  however,  unjustifiable  and  injurious  to  the  progress  of  true 
science  if  one  neglects,  in  the  study  and  description  of  what  the  new  forma- 
tions of  the  various  organs  have  in  common,  the  right  of  the  individual 
organ,  which  requires  that  one  regard  the  pathological  new  formations  as 
a  disturbance  of  its  development,  its  nutrition,  or  its  decomposition.  But  be 
it  well  understood  I  am  very  far  from  disputing  the  usefulness,  nay,  the 
necessity,  of  general  observations  of  pathological  new  formations.  These 
observations,  however,  ought  to  proceed  more  upon  establishing  the  principle 
of  development  than  upon  finding  out  certain  anatomical  models,  according 
to  which  a  new  formation,  for  example  cancer,  is  built,  as  well  in  this  as 
in  that  organ.  Moreover,  if  I  understand  our  time,  it  is  tired  of  purely 
external,  anatomical  classifications,  and  decides  with  me  that  it  has  become 
scandalous  in  the  inexhaustible  multiplicity  of  concrete  forms.  We -will,  of 
course,  therefore  speak  in  what  follows  of  cancers  and  sarcomas  ;  we  will  take 
pains  to  delineate  the  laws  of  their  production  and  their  growth  in  bold  out- 
lines, also  not  to  exclude  observations  upon  their  effects  upon  the  entire  organ- 
ism, therewith,  however,  constantly  reflecting  upon  the  description  of  the 
individual  forms  in  the  special  part,  and  remaining  conscious  that  the  knowl- 
edge of  these  is  at  least  just  as  important  to  the  physician  as  is  the  general 
comprehension. " — Rindfleisch. 

"  Upon  an  anatomical  basis  we  must  separate  those  tumors  which  are  the 
result  of  an  actual  formative  process  (pseudoplasms)  from  those  which  have 
a  different  origin.     The  latter  correspond  to  the  majority  of  what  were  for- 


808  ORAL  DISEASES  AND   SURGERY.  • 

Clinical  Illustrations,  in  Diagnosis.  —  A  patient  presents 
himself  to  the  surgeon,  having  a  tumor  in  his  groin.     What  is  the 

merly  called  tumores  cystici.  Those  tumors  which  are  not  the  product  of  a 
real  growth  owe  their  existence  either  to  material  that  comes  direct  from  the 
blood,  or  to  the  accumulation  of  certain  secretions.  If  the  material  comes 
from  the  blood,  it  may  be  deposited  in  three  forms  :  1,  Blood  in  substance, — 
extravasation  :  2,  serum,  containing  water,  salts,  and  albumen, — transudation  ; 
or,  finally,  3,  a  certain  amount  of  fibrin  with  the  serum, — exudation.  In 
some  instances  there  will  be  found  an  exudation  and  an  extravasation  together 
in  the  form  of  a  hemorrhagic  exudation;  or  with  a  large  amount  of  serum 
there  Avill  be  found  a  small  quantity  of  fibrin, — a  serous  exudation. 

"  Those  tumors  which  represent  the  accumulation  of  certain  secretions 
diflfer  in  the  following  respects  :  the  contents  may  be  chiefly  fluid,  or  chiefly 
organized  elements,  or  may  consist  of  both.  These  cystic  tumors  form  a  class 
by  them.selves.  The  accumulation  takes  place  in  a  pre-existing  space,  which 
becomes  dilated  or  ectasic  in  proportion  to  the  accumulation  of  the  secretion. 
These  tumors  could  be  called  ectases,  but  there  is  something  besides  ectasis, 
namelj',  the  retained  secretion.  We  shall,  therefore,  call  them  dilatation  or 
retention  tumors. 

"  The  tumors  of  the  first  class,  which'consist  chiefly  of  the  elements  of  the 
blood  (extravasations,  transudations,  or  exudations),  may  either  originate  in 
a  pre-existing  space,  or  form  for  themselves  a  new  space.  These  we  shall  call 
extravasation  or  exudation  tumors. 

"  In  this  way,  leaving  out  the  entozoa  and  simple  swellings,  we  obtain 
three  large  groups  or  classes  :  first,  the  exudation  and  extravasation  tumors  ; 
second,  the  dilatation  and  retention  tumors;  and  last,  the  true  pseudoplasms 
or  neoplasms, — the  growths  in  the  strict  sense  of  the  word.  The  last  class, 
as  we  have  already  seen,  may  be  again  divided  into  three  smaller  classes :  the 
simple  histoid,  the  organoid,  and  the  teratoid  tumors.  Unfortunately,  the 
classification  cannot  stop  here,  for  there  are  many  tumors  in  which  ditfercnt 
varieties  are  combined  together.  These  are  called  combination  tumors.  In 
some  cases  these  combination  tumors  are  exceedingly  difficult  to  comprehend. 

"All  heterologous  tumors  are  not  malignant.  Quite  a  number  of  them  are 
practically  benign,  and  may  be  carried  without  ever  causing  any  special 
trouble.  In  the  first  place,  there  are  degrees  of  heterology.  The  tissues 
belonging  to  the  group  of  copnective  substances  are  more  nearly  related  to 
ehch  other  than  to  the  epithelial  tissues.  If,  therefore,  a  cartilaginous  or 
bony  tumor  originates  in  the  midst  of  connective  tissue,  or  a  myxoma  (mucous 
tissue)  in  adipose  tissue,  the  heterology  in  these  cases  will  be  far  less  than  if 
an  epidermoidal  tumor  were  to  originate  in  the  midst  of  a  Ij-mphatic  gland. 
A  matter  of  still  greater  importance  is  the  extent  to  which  a  tumor  can  pro- 
duce fluid  material,  that  may  be  pressed  out  like  a  juice.  This  parenchyma- 
tous juice  is  at  one  time  deposited  within  the  cells  (intracellular),  at  another 
between  them  (intercellular).  A  tumor  containing  much  juice  possesses  to  a 
high  degree  the  power  of  infection.  A  dry  epidermoidal  tumor  is  much  less 
dangerous  than  a  moist  one ;  a  soft  cancer  is  much  more  suspicious  than  a 


TUMORS.  809 

nature  of  this  tumor  ?  It  might  have  the  local  signification  of  a 
hernia  ;  of  an  undescended  testicle  ;  of  a  hydrocele  of  the  spermatic 
cord ;  of  an  inflamed  lymphatic  gland.  It  might  have  the  consti- 
tutional explanation  of  syphilitic  or  of  tuberculous  bubo.  It  might 
be  a  cancer.  To  satisfy  himself  of  the  particular  condition  repre- 
sented, the  surgeon  can  only  proceed  as  follows.  First,  he  must 
recall  the  anatomy  of  the  part.  In  the  groin  of  the  human  male  is 
a  canal, — the  inguinal  canal.  This  canal  is  entered  by  a  ring  from 
the  abdominal  cavity,  and  has  an  outlet  in  a  second  existing  in  the 
aponeurosis  of  the  external  oblique  muscle.  In  this  canal  lie,  en- 
veloped in  a  sheath,  the  spermatic  vessels.  This  canal  constitutes 
the  passage  transmitting  the  testicle  from  the  abdomen  to  the  scro- 
tum. The  entrance  to  this  canal  may  permit  of  the  insinuation  of  a 
knuckle  of  omentum  or  intestine.  In  this  inguinal  region  exist  a 
number  of  lymphatic  glands.  This,  then,  is  the  anatomy,  and  these 
are  the  data.  Is  the  tumor  a  hernia  ?  There  is  no  impulse  on  cough ; 
no  doughy  feel ;  no  diminution  in  size  when  the  patient  lies  down  ; 
no  ability  to  thrust  the  tumor  into  the  abdomen ;  no  enlargement  of 
the  internal  inguinal  ring.  The  tumor  is  not  a  hernia.  Is  it  an  un- 
descended testicle?  The  testicle  is  to  be  felt  in  its  place  in  the  scro- 
tum. The  tumor  is  not  a  testicle.  Is  it  hydrocele  of  the  spermatic 
cord  ?  Thei'e  is  no  fluctuation  on  percussion  ;  no  ability  to  change 
the  position  ;  no  fluid  as  test  is  made  with  the  exploring-needle  or 
suction  syringe.  It  is  not  hydrocele.  Is  it  an  inflamed  gland  of  a  local 
inflammatory  signification  ?  It  has  no  such  history.  The  tumor, 
then,  is  not  of  immediate  signification  ;  this,  it  would  seem,  we  must 
know  to  a  certainty.  By  exclusion,  then,  such  tumor  is  exhibited  as 
belonging  to  the  second  class.  The  only  question  now  is  as  to  the 
vice  represented.  Syphilis  and  tuberculosis  have  a  history.  If  such 
history  does  not  exist,  then  a  final  exclusion  pronounces  the  condi- 
tion— whether  rightly  or  wrongly  need  not  here  be  discussed — a 
cancer. 

Example. — At  a  late  clinic  of  the  University  Hospital  there  ap- 
peared before  the  class  five  patients.  These  patients,  suffering  alike 
from  swollen,  enlarged  cheeks,  were  ranged  side  by  side  for  diag- 
nosis.    Patient  1  w^as  found  to  have  the  tumefaction  dependent  on 

hard  one.  The  fewer  vessels  a  honor  possesses,  the  more  will  its  infecting  power 
be  restricted  to  the  immediate  neighborliood ;  but  the  richet  it  is  in  blood-  and 
lymph-vessels,  the  closer  the  contact  of  these  two  fluids  xoiih  the  parenchymatous 
juices,  and  the  easier  luill  the  infection  become  general." — Virchow:  Abstract 
from  Lectures,  made  by  Drs.  Buck  and  Delafield. 


810  ORAL  DISEASES  AND   SURGERY. 

a  periodontitis;  patient  2  was  laboring  under  caries  of  the  jaw; 
patient  3  suffered  from  necrosis ;  patient  4  had  a  lymph  effusion  con- 
sequent on  a  fracture ;  patient  5,  with  very  limited  swelling  of  the 
cheek,  associated  with  enlargement  of  the  maxilla,  presented  in  his 
case  no  local  or  common  systemic  explanation  ;  it  became  thus 
a  necessity  to  pronounce  the  disease  associated  with  the  vice  of 
cancer.  The  first  four  patients,  their  cases  being  self-explaining, 
were  quickly  made  well  ;  the  last — whose  case  was  without  an 
accounting  explanation— died,  and  died  from  that  condition  which, 
in  its  developed  state,  was  by  all  called  carcinoma. 

With  the  premises  of  the  preceding  pages,  for  the  purposes  of 
the  chapter,  assumed,  it  is  to  be  understood  that  any  tumor,  wher- 
ever situated,  being  without  a  history  which  explains  it,  is  to  be 
called  and  treated  as  cancer.  But  here  at  once  may  seem  to  rise 
insurmountable  objections  to  such  classification.  It  might  be  urged, 
for  example,  that  a  spindle-cell  sarcoma  which  shall  not  destroy  life 
has  no  more  explanation  of  its  origin  than  has  an  encephaloma, 
which  in  a  single  year  runs  to  a  fatal  end.  Such  objection,  however, 
influences  only  the  histologist ;  the  clinician  recognizes  no  prac- 
tical difference  between  the  two  conditions :  they  are,  he  assumes, 
but  expressions  of  a  common  vice.*  But  the  one  will  kill,  and 
the  other  may  not.     If  this  is  urged,  the  objection  is  admitted;  but 


*  "  Over  no  group  of  tumors  has  there  so  long  been  uncertainty  about  their 
anatomical  position  and  extent  as  about  sarcoma.  The  old  name,  taken  from 
aap^,  flesh,  merely  meant  that  on  section  the  tumor  had  a  fleshy  look.  Of 
course,  this  did  not  make  a  diagnosis,  as  it  was  greatly  a  matter  of  choice 
what  should  be  called  flesh.  The  attempt  to  employ  the  name  sarcoma  solely 
for  tumors  composed  of  muscle  filaments  (Schule),  that  is,  to  identify  it  with 
those  tumors  now  called  '  myoma,'  was  not  popular.  Subsequently  the  term 
became  somewhat  more  definite, — it  was  made  to  include  all  tumors  rich  in 
cells  which  have  no  decided  alveolar  formation,  and  were  not  carcinomatous. 
It  is  onh'  for  the  last  ten  years  that  the  following  histological  definition  has 
received  general  acceptance,  and  has  become  quite  common.  A  sarcoma  is  a 
tumor  consisting  of  tissue  belonging  to  the  developmental  series  of  connective- 
tissue  substances  (connective  tissue,  cartilage,  bone,  muscles,  and  nerves), 
which,  as  a  rule,  does  not  go  on  to  the  formation  of  a  perfect  tissue,  but  to 
peculiar  degenerations  of  the  developmental  forms.  Some  pathologists  would 
gladly  see  muscles  and  nerves  excluded  from  this  definition ;  but  when  speak- 
ing of  the  spindle-celled  sarcoma  I  shall  show  why  I  cannot  admit  this.  If  it 
is  desired  to  term  the  inflammatory  neoplasiie  in  their  various  stages  examples 
of  sarcoma  (Rindflcisch),  I  assent  to  it,  as  this  definition  would  agree  pretty 
well  with  mine." — Billroth. 


4 


TUMORS.  811 

it  has  an  explanation  which  is  easily  made  evident.  There  is,  we 
say,  but  one  non-explaining  vice ;  this  vice  puts  oti  various  phases. 
These  phases  are  influenced  by  the  malignancy  of  the  poison,  or  by 
relation  with  the  conditions  of  the  individual  into  whose  system  it 
has  found  ingress.  This  we  may  illustrate  by  an  example.  Four 
men  go  from  a  healthy  to  a  malarious  district ;  all  live  in  the  same 
house,  and  all  impregnate  their  systems  with  the  same  poison.  In 
a  week  one  succumbs  to  a  quotidian ;  in  two  weeks  the  second  has 
a  tertian;  in  three  weeks  the  third  dies  from  congestive  chill;  while 
the  fourth,  preserved  by  an  inherent  resistive  force,  antagonizes  the 
miasma  entirely.  Thus  also  in  the  cancer  vice :  one  man,  either 
from  the  concentration  of  the  virus  or  from  the  absence  of  antago- 
nizing power,  dies  quickly  from  a  medullary  expression;  while  an- 
other maintains  a  tumor  for  years,  in  the  expression  of  simple  sar- 
coma, succumbing  finally  in  the  battle,  which,  by  the  accident  of  some 
loss  of  force,  gives  a  mastery  to  the  abeyant  vice,  the  sarcoma  being 
quickly  degraded  into  that  which  the  microscope  has  distinguished 
from  it  as  carcinoma.     (See  Sarcomatous  Carcinoma.) 

The  premise,  then,  is  to  be  maintained,  that  any  and  every  tumor 
which  cannot  be  proved  benign  is  to  be  deemed  malignant.  A 
self-explaining  tumor  expresses  its  own  name;  a  non-explaining 
tumor  demands  from  us  no  special  regard  for  the  distinctions  of 
nomenclature,  except  as  in  an  adjectival  way  the  distinctions  classify, 
for  convenience  in  description,  what  are  to  be  regarded  as  varying 
expressions  of  a  common  disease.     (See  Fibroma.) 

Urging  the  conviction  that  in  the  preceding  few  and  very  simple 
rules  lies  the  fullness  of  a  proper  clinical  diagnosis  of  tumors,  appli- 
cable to  any  and  all  cases,  we  may  now,  without  the  chance  of 
becoming  confused,  proceed  to  acquaint  ourselves  with  the  tumors 
pertaining  to  the  parts  which  it  is  the  special  object  of  this  volume 
to  study.  Before  doing  this,  however,  a  comprehensive  discussion 
of  the  subject  at  large  may,  with  greater  justice  to  our  distinctions, 
invite  the  attention  of  the  student.* 

*  But  it  is  to  be  asked  whether  or  not,  outside  of  the  negation  of  the  self- 
explaining  tumors,  there  is  a  something  that  may  distinguish  a  cancerous 
tumor  ?  If  there  is,  the  author  knows  nothing  about  it ;  but  this  negation 
has  a  wide  meaning.  According  as  a  man  knows  of  a  certainty  what  is  not 
cancer,  his  inference  of  cancer  becomes  reliable  and  valuable  :  he  calls  that  a 
cancer  which  has  its  place  outside  of  the  positive  diagnostic. 

But  is  there  not  some  special  histological  expression  which  characterizes 


812  ORAL  DISEASES  AND  SURGERY. 

1.  Relationship. — Homologous  tumors  tend,  as  would  be  in- 
ferred, to  preserve  their  individuality;  a  malignant  growth,  on  the 
contrary,  represents  simply  the  nidus  of  a  vice  flowing  in  from  all 
parts,*  and  unless  this  poison  become  exhausted,  or  be  powerfully 
resisted,  it  is  seen  to  tend  to  infiltration  and  a  commingling  with  all 
adjacent  tissues. 

2.  Homologous  tumors  progress  regularly,  are  apt  to  remain 
stationary  after  attaining  some  certain  size,  as  in  an  odontocele,  or 
they  may  degenerate  and  slough,  as  seen  frequently  in  nsevi  and  in 
the  sebaceous  growths.  In  structure,  homologous  tumors  are  akin 
with  the  parts  in  which  they  are  found  ;  they  do  not  possess  other 
than  a  single  formative  capacity.  The  tumors  of  a  vice,  on  the 
contrary,  have,  as  a  rule,  associated  with  them  the  evidences  of 
their  systemic  character.  They  are  not  amenable  to  a  local  cure : 
if  one  be  removed,  a  second  comes  to  take  its  place,  appearing  either 
in  the  site  of  removal  or  in  some  other  locality. f  The  cure  of  a 
vice  tumor  resides  either  in  the  use  of  a  specific,  antidoting  the 
poison  of  the  vice,  or  in  affording  such  increase  of  the  natural 
resisting  force  that  the  destructive  tendency  is  retarded  or  over- 
come. 

3.  Homologous  tumors  are  commonh^  single,  or,  if  multiple, — for 
example,  sebaceous  cysts, — are  confined  to  a  common  tissue  and  a 
common  association.  The  vice  tumors  exhibit  their  constitutional 
association  in  the  tendency,  as  just  remarked,  to  reproduction  not 
only  in  various  parts,  but  in  various  tissues. 

4.  Homologous  tumors,  if  painful,  express  a  common  pain.  Vice 
tumors  are  apt  to  have  a  character  of  pain  peculiar  to  themselves. 

1.  Simple  LiJIamviatory  Tumora. — A  simple  inflammatory  tumor 
refers  to  a  swelling  (which  is  of  varying  nature),  associated  with  an 
inflammation :  thus,  it  may  depend  on  simple  excess  of  blood  in  a 
part,  or  on  effusion  of  serum  or  of  lymph. 

Vascular  excitement,  of  a  grade  which  brings  a  perverted  circula- 
tion under  cognizance  as  inflammation,  never  increases  the  dimen- 

cancer, — some  peculiar  heteroclitic  cell  ?  Once  it  was  thought  so  ;  but  now  it  is 
known  that  the  spindle-cells,  deemed  a  few  years  back  entirely  diagnostic,  are 
also  found  in  foetal  connective  tissue,  muscles,  and  nerves.  Spindle-cells 
afford  information  to  diagnosis  from  location  and  combinations  alone. 

*  This  view  has  the  indorsement  of  the  eminent  surgeon  and  pathologist, 
Mr.  Paget. 

f  This  is  attempted  to  be  explained  by  Yirchowon  the  principle  influencing 
syphilitic  absorption,  or  rather,  to  express  him  more  critically,  by  embolism. 


TUMOBS.  813 

sions  of  a  part  through  excess  of  nutritive  or  formative  action  ;  on 
the  contrary,  the  nutrition  of  an  inflamed  part  is  always  diminished, 
this  being  amply  demonstrated  by  the  disorganization  of  suppura- 
tion. p]ven,  however,  in  the  cases  where  I'esolution  occurs,  the 
tissues  are  always  left  relaxed  and  degenerate,  and  in  themselves 
are,  without  doubt,  of  less  consistence  by  weight  or  bulk  than  before 
the  attack. 

It  is,  however,  as  is  well  understood,  a  characteristic  of  vessels 
engaged  in  inflammatory  action  to  relieve  their  distention  through 
effusion,  and  thus,  as  such  effused  material  may  be  serum,  tibro-serum, 
blood,  or  lymph,  tumefaction  is  produced,  which  is  persistent  or 
otherwise  according  to  character  and  associations. 

Concerning  the  first, — the  simple,  unmixed  watery  effusions, — they 
are  found  most  frequently  associated  with  low  degrees  of  inflamma- 
tion, as  in  certain  articular  affections,  in  encephalocele,  hydrocele, 
etc.  In  such  effusions  there  can  be  no  tendency  either  to  coagulation 
or  to  organization :  a  tumor  is  formed,  but  it  is  simply  a  water-bag. 
Fibro-serum,  or  serum  containing  fibrin,  has  in  it,  however,  an 
organizing  force  proportioned  to  the  quantity  of  fibrin  contained, 
approaching  to  this  extent  the  nature  and  character  of  lymph  :  such 
fibro-serum  is  seen,  on  withdrawal  from  the  body,  to  differ  from 
serum  proper  in  the  ability  it  possesses  to  assume  a  jelly-like  con- 
sistence, and,  indeed,  to  show  the  fibre-cell,  as  exhibited  in  the  peri- 
toneal and  pleural  efl'usions.  Fortunately,  however,  while  excluded 
from  the  air,  fibro-serum  seldom  manifests  any  tendency  to  coagulate, 
thus  remaining  as  susceptible  to  the  action  of  the  absorbents  as  is  the 
more  simple  effusion.  Fibro-serum  is  the  liquor  sanguinis  of  Babing- 
ton,  the  plasma  of  Schultz,  the  mucago  or  mucilage  of  Harvey. 

Lymph,  another  of  the  exudates  of  an  engorged  vessel,  finds  its 
most  practical  expression  when  viewed  as  the  agent  of  nutrition;  it 
is  that  pabulum  in  which  reside  the  elements  of  life,  and  is  in 
a  state  of  constant  transmission  to  every  part  of  the  organism : 
only  as  the  result  of  over-pressure  or  engorgement,  however,  is  it 
likely  to  be  found  in  excess  in  any  one  part;  but  when  so  found  it 
compels  a  tumefaction,  to  the  proportion,  of  course,  of  the  amount 
exuded. 

Between  lymph  and  the  vitalizing  principle — the  vis  vitse — there 
exists  the  most  marked  affinity  ;  so  that  the  circumstances  must  be 
adverse  indeed  where  exuded  lymph  does  not  tend  to  organization. 
Corpuscular  lymph,  as  it  is  sometimes  termed,  to  distinguish  a  less 
vital  from  fibrinous  lymph,  is,  when  employed — as  is  not  uncommon 


814  ORAL  DISEASES  AND  SURGERY. 

— to  express  the  existence  of  two  kinds  of  Ij'mph,  a  physiological 
misnomer, — the  difference  lying  not  in  kind,  but  in  character:  thus, 
while  lymph  exuded  by  a  vigorous  organization  tends  always  to 
immediate  organization,  cells  being  developed  in  the  blastema,  and 
fibres  developing  from  cells,  in  a  specifically  diseased  person,  or  in 
one  deficient  in  the  vital  element,  the  recognition  of  cause  for  de- 
generation is  sufficient  explanation  of  a  corpuscular  variety.  Cor- 
puscular lymph  is  protoplasm  the  grade  of  organization  of  which 
fails  to  rise  to  a  proper  development;  the  ver}''  common  admixture 
of  these  two  varieties  is  evidence  enough  of  the  oneness. 

Lymph  tumors  have  associated  vyith  them  a  threefold  sequelte  : — 
the  contents  are  absorbed  ;  or  they  organize ;  or  they  degenerate 
and  are  gotten  clear  of  in  suppuration :  or  the  three  conditions  may 
coexist,  part  of  the  lymph  being  absorbed,  part  being  thrown  off  by 
degeneration  and  suppuration,  and  a  portion  affiliating  itself  with 
the  surrounding  parts. 

2.  Hypertrophic  Tumors.  —  Hypertrophy  is  an  expression  of 
unbalanced  nutrition, — a  part,  from  some  reason  (recognizable,  or 
not  so),  developing  in  excess  of  its  fellow-parts.  Hypertrophic 
tumors  differ  from  all  others,  however,  in  their  perfect  and  complete 
conformity  with  the  parts  with  which  they  may  be  associated.  So 
marked  and  characteristic  is  this  that  it  is  only  through  comparison 
with  neighboring  parts  that  the  tumefaction  or  enlargement  is  to  be 
perceived.  Hypertrophy  may  ensue  from  the  opposite  conditions 
of  excessive  supply  or  of  diminished  waste.  The  enlarged  biceps 
muscle  of  the  blacksmith,  and  the  gastrocnemii  of  the  ballet-dancer, 
are  illustrations  of  hypertrophy  from  super-nutrition.  Enlarged 
glands  from  tuberculosis  are  not  justly  to  be  considered  in  such  a 
connection,  being  specific  hypertrophies:  the  first  are  hardly  to  be 
pronounced  pathological,  the  latter  are  necessarily  so  ;  the  first  have 
no  expression  but  health,  the  latter  none  but  disease. 

8.  Tumors  xchich  result  from  Interference  ivith  Function. — The 
appreciation  of  this  class  of  tumors,  of  which  there  are  a  great 
number,  is  commonly  without  confusion  or  difficulty.  It  is,  of 
course,  required  that  the  observer  shall  draw  his  inferences  from  the 
data  of  an  anatomical  and  physiological  knowledge.  The  opened 
spinal  canal  gives  the  protruding  meninges, — the  fluid  of  the  cord 
filling  the  fluctuating  cyst;  obstructed  sebaceous  ducts  yield  wens  ; 
relaxed  veins  afford  varices;  occlusion  of  the  antral  foramen  compels 
engorgement  of  this  cavity  ;  an  unclosed  umbilicus,  or  attenuation 
of  its  structures,  and  hernia  follows ;    a  tooth  out  of  the  dental 


TUMORS. 


815 


arch,  yet  developing  within  the  structure  of  the  bone,  and  odon- 
tocele  is  apt  to  ensue.  So  of  all  this  class  of  tumors  we  have  similar 
simple  and  single  significations;  the  pathology  of  each  is  peculiar 
to  itself,  but  may  be  esteemed  as  almost  strictly  mechanical. 

4.  Blood  Effusion. — It  not  unfrequently  happens  that  an  inflam- 
matory engorgement  is  associated  with  rupture  of  certain  of  the 
minute  blood-vessels,  thus  allowing  of  the  mechanical  pouring  out 
of  the  blood  into  neighboring  parts.  Such  tumors  find  diagnosis  in 
the  suddenness  of  their  formation  and  the  associated  inflammatory 
condition  ;  they  are  simply  blood-bags,  which  may  be  more  or  less 
sacculated  according  to  the  circumstances  of  location.  A  blood  effu- 
sion differs  so  markedly  from  a  najvus  or  erectile  growth,  that  by 
no  possibility  could  these  be  confounded.  Blood  effusions  may  be 
absorbed,  may  be  organized,  or  may  degenerate  and  break  down, 
being  gotten  clear  of  through  the  suppurative  process. 

Another  class  of  blood  tumors  are  of  traumatic  signification.  A 
hsematocele  is  not  unfrequently  resultant  from  injury  rupturing 
vessels.  The  common  blood  blister  is  an  example  familiar  to  every 
one. 

Histological  Distinctions. — A  common  classification  of  tumors, 
as  employed  b}'  nearly  all  writers,  is  founded  on  what  are  termed  the 
histological  aspects  of  the  growths  described.  The  philosophy  of 
such  classification  finds  condemnation  in  the  changes  constantly 
occurring,  and  in  the  fact  that  the  clinical  history  of  the  conditions 
demonstrates  the  expressions  to  be  phenomenal,  just  as,  though  in 
more  marked  degree,  the  expressions  of  vascular  perversion  which 
we  denominate  inflammation  are  phenomenal. 

The  classes  of  tumors,  as  histologically  described,  are  as  follows : 


Cystoma Cystic. 

Enchondroma  ...Cartilaginous. 

Fibroma Fibrous. 

Lipoma Fatty. 

Osteoma Osseous. 

Dentinoma Dentinal. 

Hsematoma Blood. 

Encephaloma.... Brain-like. 

Scirrhoma Marble-like. 

Melanoma Like  black  pigment. 

Myxoma Mucus-like. 


Adenoma Glandular. 

Angionoma Vascular. 

Sarcoma Fleshy. 

Neuroma Nerve-like. 

Hygroma Water-like. 

Steatoma Lard-like. 

Myeloma Marrow-like. 

Meliceroma Honey-like. 

Atheroma Gruel-like. 

Chloroma Like  green  pigment 


816  OBAL  DISEASES  AND  SURGERY. 

A  single  moment's  reflection  will  show  that  no  conflict  can  exist 
between  such  a  histological  classification  and  the  clinical  one  here 
proposed.  An  angionoma  may  be  homologous  or  heterologous.  A 
hematoma  may  be  benign  or  malignant.  Let  us  analyze,  in  illus- 
tration, some  of  the  terms. 

We  say,  for  example,  of  a  certain  tumor,  that  it  is  a  cystoma. 
Using  this  term,  we  imply  in  it  a  cystiform  character  of  growth, — 
this,  and  nothing  more.  The  tumor  may  readily  enough  be  what 
we  have  called  homologous  ;  for  should  the  cyst  be  in  tbe  jaw-bones, 
and  should  we  make  examination,  we  might  remark  the  absence  of 
certain  teeth  from  the  arch  affected,  and,  on  chiseling  off  the  vault 
of  the  cyst,  we  might  find  the  lost  teeth  as  an  explanation  of  the 
growth:  the  cyst  would  be  a  self-explaining  odontocele. 

Again,  examining  a  similar  form  of  cyst,  we  find  no  teeth  absent 
from  the  arch  ;  no  diseased  teeth,  nothing  that  has  in  it  the  sem- 
blance of  explanation  ;  the  most  accurate  inspection,  founded  on 
the  most  profound  knowledge  of  the  parts,  reveals  no  cause  why 
a  cyst  should  have  developed  in  such  place  and  at  such  time.  Here 
the  most  experienced  surgeon  has  but  a  single  resource.  He  must 
act  on  the  premise  that  the  condition  is  the  expression  of  constitu- 
tional vice, — not  that  this  would  necessarily  be  so,  but  that  he  does 
not  know  it  be  otherwise ;  and  therefore,  not  seeing  or  knowing  what 
is  to  be  done,  his  best  plan  will  be  to  do  nothing, — awaiting  develop- 
ment,— or  else  treat  the  cyst  with  the  latitude  of  cancer. 

Take  a  third  condition  of  cyst, — a  cyst  in  the  substance  of  the 
lip.  Is  this  homologous,  or  is  it  heterologous  ?  Is  it  a  self-explaining 
condition,  or  does  it  express  the  habitat  of  a  vice  ? 

In  the  substance  of  the  lip  are  secreting  glands  of  three  characters, 
mucous,  sebaceous,  and  sudoriparous;  each  of  these,  for  the  purpose 
of  clinical  study,  may  be  described  as  a  secreting  cyst-like  body  with 
a  patulous  tube  running  from  it  to  a  free  surface,  through  which 
tube  is  constantly  being  discharged  the  fluid  formed  in  the  cyst. 
Suppose  now  any  one  of  these  tubes  to  be  accidentally  occluded, 
we  find  ourselves  led  at  once  to  an  apprehension  of  a  diagnosis. 
Should  a  labial  cyst  be  mucous  in  its  character,  it  will  be  a  soft, 
more  or  less  elastic  tumor,  will  be  situated  upon  the  oral  aspect 
of  the  lip,  and  if  explored  by  the  needle  will  yield  the  characteristic 
discharge.  Should  the  cyst,  on  the  contrary,  be  of  a  sebaceous 
nature,  it  will  be  related  with  the  external  tissue,  will  roll  loosely 
under  the  touch,  and  if  explored  will  exhibit  cheese-like  contents. 
The  sudoriparous  cyst  is,   of  course,  of  very  rare  occurrence  ;    if 


TUMOES.  817 

existing,  it  would  also  lie  in  the  external  tissue,  and  would  be  found 
to  have  much  more  elastic  walls  than  either  of  the  others.  A  cyst 
sometimes  will  be  found  in  the  lip  dependent  upon  dental  abscess. 
A  case  is  at  the  present  time  under  treatment  by  the  author  where 
such  a  cyst  has  been  of  eleven  years'  standing ;  during  all  this 
period  the  tumor  has  not  been  of  less  size  than  an  ordinary  shell- 
bark-nut.  The  sac  was  found  very  thick,  and  the  surface  ulcerated. 
A  treatment  which  consisted  simply  in  the  extraction  of  two  dead 
teeth,  has  resulted  in  the  entire  disappearance  of  the  cyst.  The 
alveoli  of  these  teeth  were  found  to  associate  with  the  tumor.* 

We  pass  to  other  of  these  synonyms.  Let  us  take  the  terms 
scirrhoma,  myxoma,  encephaloma,  myeloma:  these  are  names  given 
to  tumors  because  of  peculiarities  of  structure.  The  clinical  placing 
of  them,  however,  is  the  practical  matter.  Whatever  name  the  his- 
tologist  employs  for  the  designation  of  a  tumor,  whatever  may  be 
the  histology  of  the  growth,  its  clinical  place,  if  no  local  explana- 
tion exists,  is  with  cancer.  Here  only  may  it  be  placed  as  treatment 
is  concerned,  and  with  such  latitude  of  doubt,  however  profound  may 
be  his  histological  learning,  is  the  surgeon  made  to  feel  that  he 
must  treat  it. 

Scirrhoma  is  a  term  employed  to  designate  solidity,  hardness  ;  the 
cancer  vice,  influenced  by  the  associations  of  a  part  in  which  it  is 
found,  by  its  own  character,  or  by  some  peculiarity  or  idiosyncrasy  of 
the  individual,  exhibits  itself  as  a  hard  nodule  ;  remove  this  nodule, 
and  not  unlikely  the  return  of  the  disease  is  in  the  form  of  a  brain- 
like substance, — encephaloma  ;  or  that  might  come,  which,  cut  into, 
would  exude  a  mucus-like  substance,  and  we  might  call  it  a  myx- 
oma; or  perhaps  a  section  would  exhibit  marrow-like  contents, — 
myeloma;  or  there  might  be  a  cyst  with  gruel-like  contents, — 
atheroma.  Or,  diffused  throughout  the  substance  of  any  of  these 
differently  appearing  conditions,  there  might  be  a  black  coloring- 
matter, — then  we  might  express  the  tumor  as  a  melanoma;  should  the 
pigment  be  of  a  green  shade,  we  would  call  it  chloroma ;  or  should 
we  designate  the  tumor  for  the  first  time,  on  seeing  it  in  a  state  of 

*  The  hydatid,  being  a  cyst  of  parasitic  origin,  is  not  introduced.  Sucli  a 
cyst,  being  an  accident,  as  it  were,  can  be  conformed  to  no  rule.  For  pur- 
poses of  treatment,  however,  these  tumors,  however  much  they  might  be 
misjudged,  have  every  requirement  met  in  such  operations  as  consider  the 
circumscribed  and  antagonized  cancer  growth  (which  see).  The  clinical 
distinction  makes  necessarily  unimportant  the  mistake — as  treatment  is 
concerned — of  classifying  the  hydatids  with  the  cancer  vice. 

51 


818  ORAL  DISEASES  AND  SURGERY. 

fungous  proliferation,  we  should  call  it  a  hsematoma.  Yet,  with  all 
these  various  significations,  we  would  mean,  in  truth,  but  a  single 
thing:  and  to  clinically  classify  any  or  all  of  these  phases  we  would 
need  but  one  common  term, — that  is,  taking  it  for  granted  that  the 
tumors  were  without  local  explanation.  In  such  exposition  of 
terms,  which  are  seen  to  be  simply  expressive  of  types, — synonyms 
we  may  with  all  propriety  call  them, — any  confusion  must  certainly 
be  found  dispelled.  These  various  terms,  as  employed  in  writing, 
are,  however,  of  great  assistance  in  expression;  it  is  only  necessary 
to  bear  in  mind  that  their  meaning  and  relation  are  adjectival. 


CHAPTER    XXXIX. 

THE   TUMORS   OF   THE   MOUTH. 

THE   EPULIDES. 

The  Epulides. — The  tumors  of  the  mouth  most  frequently  met 
with  are  those  seen  growing  upon  the  gums,  and  known  as  the  epulic. 
These  growths  are,  in  almost  all  instances,  first  to  be  observed 
,  making  their  way  from  about  the  neck  of  some  particular  tooth, 
pushing  out,  apparently,  from  the  socket,  being  found  to  originate 
from  the  odonto-alveolar  membrane. 

As  the  epulides,  like  other  tumors,  classify  themselves  into  self- 
explaining  and  non-explaining,  the  term  epulis,  still  in  quite  com- 
mon use,  is  without  proper  signification  when  employed  as  a  noun 
substantive,  being  possessed  of  an  adjectival  sense  only.  This  term 
is  derived  from  the  Greek  words  ^-c  and  oZXa,  signifying  "  upon  the 
gums,"  and  will  be  seen,  therefore,  to  express  simply  position,  so 
that,  in  employing  it,  one  can  only  express  that  the  growth  spoken 
of  is  upon  these  parts. 

Histologically  expressed,  the  epulic  tumors  might  be  classified  as 
follows:  epulo-fungoid,  epulo-erectile,  epulo-fibroid,  epulo-fibro-recur- 
ring,  epulo-sarcomatous,  epulo-myeloid,  epulo-carcinomatous,  epulo- 
cartilaginous,  etc.  Clinically  classified,  we  have  to  concern  our- 
selves only  with  the  benignancy  or  malignancy  of  the  growths,  as 
thus  alone  may  we  be  led  to  a  required  treatment. 

The  single  epulic  tumor  which  may  with  certainty  be  known  as 
benign  is  the  pulp-fungoid.  A  second  form,  which  is  usually  found 
so,  is  the  erectile.  Any  of  the  epulides  which  does  not  exhibit  itself 
as  one  or  the  other  of  these  forms  is  to  be  deemed  cancerous,  and 
treated  with  the  latitude  given  to  cancer.  Xo  other  inference  in- 
sures the  best  good  for  the  patient. 

An  epulo-fungoid  growth  is  self-explaining.  An  erectile  tumor 
is  fairly  so  from  analogy  with  the  naevi :  it  is,  in  fact,  a  nasvus. 
No  other  of  the  epulides  possess  explanation  of  their  presence  or 
development.    The  epulo-fungoid  growths  demand  a  treatment  pecu- 

(819) 


820 


ORAL  DISEASES  AND   SURGERY. 


liar  to  themselves ;  so,  also,  do  the  erectile.  All  the  other  epulides 
are  to  be  treated  on  a  common  principle.  From  such  data,  which 
may  be  accepted  as  solidly  reliable,  the  surgeon  is  led  to  perceive 
that  an  appreciation  of  the  first  two  insures  the  clinical  understand- 
Ins:  of  all  the  other  conditions. 


The  Epulo-Fungoid  Tumor. — By  an  epulo-fungoid  tumor  is  meant 
a  fungoid  growth  of  an  exposed  degenerating  dental  pulp.  This 
tumor  is  as  common  as  it  is  simple  and  harmless,  and  is  certainly  to 
be  seen  in  a  thousand  cases  to  one  of  any  other  form.  The  fungoid 
pulp  tumor  is  met  with  under  the  various  aspects  exhibited  in  Fig. 
249. 

Referring  back  to  Fig.  44  and  description,  the  dental  pulp  is 
recognized  as  a  stroma  of  delicate  connective  tissue,  in  which  stroma 
ramify  blood-vessels  and  nerve-fibrillae  ;  this  structure  occupies  the 
cavity  of  the  tooth,  and  is  liable,  through  the  accidents  of  decay  or 

fracture,  to  become  exposed. 
Fig.  -49.  ^  When    exposed,    it    is   not 

unlikely  to  undergo  fungoid 
degeneration.  Fig.  249, 
Subfig.  1,  is  an  outline 
drawing  representing  the 
walls  of  a  tooth-root  envel- 
oping its  pulp,  which  pulp, 
slightly  fungous,  projects  a 
trifle  above  the  level  of  its 
cavity.  In  molar  roots,  the 
crown  being  gone,  such  form 
of  pulp  tumor  is  very  com- 
mon. No  difficulty  exists, 
however,  in  its  recognition, 
as  the  boundary-walls  of  the  cavity  are  plainly  to  be  observed.  A 
form  of  such  tumor,  a  trifle  complicated,  is  exhibited  in  Subfig.  2  : 
here,  as  is  seen,  the  fungus  is  of  such  extent  as  to  overlie  the  bound- 
aries of  its  canal ;  any  confusion  is  avoided,  however,  by  thrusting 
the  mass  aside,  when  its  character  is  at  once  made  evident.  Sub- 
fig. 3  represents  another  condition  :  here  the  mass  has  increased  to 
such  an  extent  that  it  not  only  conceals  the  canal,  but  also  rests  upon 
the  surrounding  gum,  to  which,  not  unlikely,  it  will  be  found  to  have 
formed  attachments.  Still  another  form  is  exhibited  in  Subfig.  4. 
Here  a  tooth-root  may  be   below  the  border  of  its   socket.      No 


Epulo-  or  dental  fungoid  tumor. 


TUMORS  OF  THE  MOUTH. 


821 


Fig.  2oO. 


pulp  projects  from  the  face  of  the  canal,  but  a  break  exists 
upon  one  side  of  the  root,  out  of  which  grows  the  fungous  mass. 
Such  a  growth,  little  by  little,  insures  the  absorption  of  the  alveolus 
upon  the  side  at  which  it  projects,  and  rising,  finally,  above  the 
free  face  of  the  gum,  exhibits  a  condition  well  calculated  to  mis- 
lead. Such  a  tumor  is  readily  distinguishable  from  the  odonto- 
periosteal  growths  by  the  nature  of  the  growth,  being  of  a  livid 
asthenic  appearance,  not  common  to  any  other  of  the  epulides. 
This  last  form  of  tumor  is  not  at  all  frequent,  depending  for  its  ex- 
istence upon  such  a  break  in  the  continuity  of  a  tooth-root  as  seldom 
occurs.  It  is  to  be  remembered,  however,  that  a  decay  commencing 
at  the  free  surface  may  run  along  the  root  of  a  tooth,  out  of  which 
track  may  project  the  fungus. 

Fungus  of  the  dental  pulp,  of  an  extent  and  character  described 
in   conditions    3    and  4,    is,  however,  as   unfre- 
quently  to  be  met  with  as  conditions  1  and  2  are 
common. 

A  form  of  epulides  simulating,  as  location  is 
concerned,  the  pulp-fungus,  is  exhibited  in  Fig. 
250.  In  this  instance  the  tumor,  while  seen  to 
arise  from  the  pulp  cavity  of  the  fang,  when  traced, 
is  found  to  be  an  outgrowth  of  that  aspect  of  the  odonto-periosteai  growth 

.  '  simulating  pulp-fungoid. 

odonto-penosteal  membrane    which   adjoins   the 
bone ;  the  growth  has  passed  through  an  opening  in  the  root,  and 
has  progressed,  as  shown  in  the  dotted  lines,  until,  reaching  the 
margin,  the  tumor  becomes  exposed.    The  drawing  shows  the  tooth 
in  section. 

To  mistake  this  last  form  of  growth  for  the  ordinary  pulp- 
fungus  would  be  to  err  necessarily  in  the  treatment,  the  four  condi- 
tions represented  in  Fig.  249  requiring  either  the  destruction  of  the 
fungus  by  means  of  cauterization,  or  the  extrac- 
tion of  the  affected  fang;  while  this  necessitates 
section  of  the  portion  of  the  jaw  found  implicated. 

Still  another  form  of  epulic  tumor*  con- 
sists, as  exhibited  in  Fig.  251,  of  a  ulitic  out- 
growth, the  result  of  irritating  influences  asso- 
ciated with  double  proximal  dental  caries ;  the 
gum  tissue,  semi-strangulated,  rises  and  fills  the 
cavities.     A  similar  expression  of  tumefaction 


Fig.  251. — Ulitic 
Tumor. 


*  This,  from  its  simplicity,  is  to  be  classed  with  the  pulp-fungoid,  as  it  is 
equally  self-explaining. 


822  ORAL  DISEASES  AND  SURGERY. 

is  not  unfrequently  met  with  in  the  interspace  existing  between 
teeth  in  which  the  Y-cut  has  been  made ;  indeed,  these  growths  are 
to  be  met  with  where  they  have  not  only  completely  filled  this  in- 
terspace, but  so  projected  above  the  grinding  face  of  the  teeth  as 
to  be  injured  at  every  occlusion  of  the  jaws.  The  treatment  consists 
either  in  extracting  one  of  the  approximating  teeth,  in  so  altering 
the  relation  of  the  necks  of  the  teeth  as  to  obviate  the  strangulation, 
or,  after  cutting  away  the  mass,  and  by  means  of  cotton  wedges 
forcing  the  structure  entirely  clear  of  the  cavity,  in  restoring  by  con- 
tour filling  the  original  relation  of  the  parts.  A  temporary  treatment 
consists  in  keeping  the  cavities  filled  with  plugs  of  cotton  saturated 
with  gum  saudarac. 

Reviewing  the  tumors  just  described,  it  is  seen  that,  with  a  single 
exception, — that  shown  in  Fig.  250, — all  are  self-explaining. 

Epulo-Erectile  Tumor. — This  is  a  vascular  growth,  the  analogue 
of  the  ntevi ;  it  is  commonly  associated  with  the  capillary  system, 
and  has  its  character  marked  by  its  variation  in  size  and  appearance 
as  influenced  by  the  conditions  of  the  circulatory  system  at  large, — 
excitement  increasing  its  turgescence,  quiet  reducing  it.  Erectile  in 
a  general  appearance,  epulo-erectile  tumors  present,  however,  decided 
features  of  variation.  Thus,  some  represent  a  congeries  of  vessels 
which  would  seem  to  need  the  merest  scratch  to  result  in  profuse 
hemorrhage.  A  more  common  feature  of  vascularity,  however, 
exists  in  a  likeness  with  the  tissue  of  the  corpus  cavernosum  penis, 
the  cellular  stroma  being  thinned  into  a  series  of  communicating 
cells,  which  are  found  congested  or  otherwise,  as  circumstances 
control.  Erectile  tumors  are  also  not  unfrequently  fouud  quite  solid, 
simulating  fibrous  structure:  this  depending  on  some  vascular  per- 
version which  has  produced  excess  of  the  fibro-cellular  element ; 
indeed,  it  has  sometimes  happened  that  spontaneous  cure  has  been 
effected  through  lymph  effusions.  The  surgeon,  acting  on  the  hint 
furnished  by  nature,  employs  such  process  as  one  of  his  means 
of  cure.  Of  the  various  forms  of  the  epulo-erectile  tumor,  the 
spongoid  is,  however,  by  far  the  most  common, — is,  indeed,  to  be 
considered  the  type :  stimulation  of  the  circulation  will  fill  it  at 
times  to  bursting  ;  pressure  may  almost  completely  empty  it. 

"Whether  an  erectile  tumor  may  come  under  the  definition  of 
arterial,  venous,  or  capillary,  depends  siuiply  on  the  vessels  most 
involved.  The  term  aneurism  by  anastomosis,  applied  to  these 
tumors  by  John  Bell,  seems  to  have  had  its  foundation  in  that 
variety  in  which  the  arterioles  are  most  implicated.     This  species, 


TUMORS  OF  THE  3I0UTH.  823 

when  congested,  presents  the  arterial  hue,  and,  when  accidentally 
wounded,  is  the  most  troublesome,  as  control  of  hemorrhage  is 
concerned.  The  venous  variety  is  made  up  of  a  congeries  of 
venules:  the  tumor  is  dark  and  commonly  somewhat  sluggish  in 
aspect.  The  capillary  form  is  intermediate  between  the  arterial 
and  the  venous,  and  constitutes  the  spongoid  form.  The  under- 
lying bone  of  the  erectile  epulides  will  almost  invariably  be  found 
involved,  being  softened  and  spongy.  Erectile  tumors  sometimes, 
though  rarely,  make  their  first  appearance  as-  a  red  pimple  upon  the 
gum,  growing  in  a  polypoid  form  until  they  may  attain  the  size  of 
a  cherry. 

Treatment. — Erectile  tumors  involving  the  bone  can  be  cured  only 
by  a  section  which  includes  this  structure.  The  diagnosis  is  easily 
secured  by  passing  an  exploring-needle  through  the  soft  tissue  : 
if  the  bone  is  implicated,  the  needle  will  be  found  to  enter  it  freely, 
and  may  be  moved  about  among  the  loose  stroma;  if  the  needle 
does  not  pierce  the  bone,  and  the  tumor  is  at  all  pedunculated,  it 
may  be  strangulated;  or,  even  where  the  base  is  broad,  the  ligature 
may  yet  be  used,  transfixing  first  the  base  with  one  or  more 
needles  for  the  proper  directing  of  the  thread. 

A  second  mode  of  treatment  is  by  injection;  the  ordinary  hypo- 
dermic syringe  being  employed,  charged  with  one  of  Monsel's 
solutions  of  iron,  with  a  very  concentrated  tincture  of  iodine,  or  with 
the  glacial  acetic  acid.  Any  substance  which  will  coagulate  the 
blood  may  be  employed,  and  not  unfrequently  is  found  to  answer  a 
very  satisfactory  end.  The  employment  of  this  means  of  cure  is 
not,  however,  unattended  with  risk.  Still  another  method  consists 
in  the  application  of  caustics,  such  as  chloride  of  zinc,  Vienna  paste, 
the  London  paste,  or  the  strong  mineral  acids.  An  anxiety,  how- 
ever, which  must  always  accompany  the  employment  of  these 
agents,  is  the  fear  of  hemorrhage  on  the  casting  of  the  slough  ; 
and  such  anxiety  is  so  well  grounded  that  experience  soon  teaches 
that  this  means  of  cure  is  applicable  only  in  the  least  vascular  of 
the  growths. 

The  seton,  as  an  agent,  finds  not  unfrequently  its  most  happy  ser- 
vice in  the  erectile  epulides.  The  needle  used  is  that  employed 
by  the  surgeon  in  the  passing  of  the  ordinary  ligature  silk.  The 
seton  may  be  soaked  or  not  in  some  caustic  solution;  the  thread  is 
always  to  be  the  thickest  that  the  eye  of  the  needle  will  admit,  in 
this  way  insuring  the  occlusion  of  the  transfixed  vessels  and 
guarding   against   bleeding.     When   hemorrhage   associates   itself 


824  ORAL  DISEASES  AND  SURGERY. 

with  such  transfixion,  alum-water  may  be  held  in  the  mouth;  or,  if 
this  does  not  answer,  tannic  acid  ma}'  be  drawn  into  the  wound 
b}'  coatings  the  seton  and  moving  it  gently  backw^ard  and  forward. 
Should  even  this  not  control  the  bleeding,  a  knitting-needle  heated 
to  whiteness  may  be  thrust  through  the  wound,  or  the  saturated 
tincture  of  iodine  may  be  injected.  On  two  or  three  occasions  the 
author  has  found  himself  enabled  to  control  such  a  hemorrhage  by 
casting  a  ligature  around  the  parts,  as  best  might  be  done,  thus 
cutting  off  the  circulation ;  indeed,  the  practitioner,  using  the 
seton,  will  on  some  occasions  find  the  employment  of  the  ligature 
forced  on  him.  Such  hemorrhages  are,  however,  very  infrequent, 
and  may  not  be  met  with  in  one  out  of  a  hundred  cases.  They 
are  most  commonly  associated  with  the  arterial  variety  of  tumor. 

Electrolysis  is  another  means  of  treatment  sometimes  employed 
(see  Ti^eatment  of  Nsevi),  and  is  highl}^  lauded  in  its  application  ; 
the  object  should  be  the  coagulation  of  the  blood,  rather  than  a 
cauterization  of  the  stroma  of  the  tumor.  Although  destruction  is 
preferred  by  many  as  the  best  service  of  electrolysis,  it  is  to  be 
recognized  that  the  mode  of  using  the  agent  suggested  has  the  ad- 
vantage, inasmuch  as  it  is  a  certain  insurance  against  hemorrhage. 

A  practice  of  "  piecemeal  removal"  has  been  introduced  into 
P^nglish  surgery,  consisting  in  teasing  or  tearing  or  twisting 
away  fragment  after  fragment ;  the  princii)le  being  to  avoid  hemor- 
rhage, as  in  the  torsion  of  arteries.  This  is  a  practice,  however, 
which  the  inexperienced  will  do  well  to  avoid ;  not  but  that,  in 
certain  cases,  it  is  a  good  plan  of  treatment,  but  frequently  it 
has  troublesome  associations,  not  the  least  of  which  is  active 
hemorrhage. 

Still  another  treatment,  employed  where  a  tumor  has  no  asso- 
ciation with  the  bone,  is  the  employment  of  the  serres-fines  :  these 
are  spring-wire  forceps ;  they  are  to  be  made  of  a  size  propor- 
tioned to  the  requirements,  and  may  be  clamped  over  the  mass.  In 
using  these  clamps,  regard  must  be  had  to  the  nature  of  the  serra- 
tions, these  being  deep  or  shallow  according  to  the  vascularity  of 
the  part  to  be  grasped ;  the  pressure  of  these  clamps  will  not  un- 
frequently  result  in  a  coagulative  and  inflammatory  action,  which 
proves  the  cure  of  the  tumor. 

An  application  somewhat  on  the  principle  of  the  serres-fines  is 
the  employment  of  pressure.  The  parts  having  first  been  emptied 
by  forcing  out  the  blood,  a  well-adjusted  compress  is  to  be  bound 
tightly  over  the  tumor,    and    retained   in   place   continuously  for 


TUMORS   OF  THE  MOUTH.  825 

several  clays  :  this  treatment,  when  the  growth  is  small,  will  often 
effect  a  cure.  An  admirable  plan  of  securing  a  desired  pressure  in 
these  cases  is  to  take  an  impression  in  wax  of  the  jaw  on  which  the 
tumor  is  situated,  and,  obtaining  thus  a  model,  make  a  plate  precisely 
as  for  artificial  teeth,  having  bands  to  hold  it  firmly  in  place,  fitted 
to  clasp  neighboring  teeth  ;  by  now  placing  over  the  tumor  a  layer 
of  cotton-wool,  and  compressing  it  by  fitting  the  plate  in  place, 
pressure  of  a  very  effective  type  will  be  found  to  have  been  secured. 
Advantage  is  also  gained  by  employing  astringents  in  conjunction 
with  the  plate  ;  saturating  the  wool  with  a  diluted  solution  of  Mon- 
sel's  solution  of  the  persulphate  of  iron  answers  a  very  good  pur- 
pose, or  tannic  acid  or  alum  may  be  used. 

The  erectile  forms  of  the  epulides,  while  not  so  clearly  explainable 
as  the  pulp-fungoid,  are  yet  to  be  esteemed  as  of  local  signification 
and  of  innocent  type.  An  analysis  of  an  erectile  growth  exhibits  it 
as  a  tuft  of  vascular  tissue.  We  recognize  in  it  vascular  anatomical 
perversion,  not  the  offspring  of  a  vice. 

From  the  consideration  of  the  epulides  as  described,  we  proceed 
to  that  of  forms,  all  of  which  experience  will  assure  us  are  best  es- 
teemed, and  with  most  benefit  and  promise  to  the  patient  treated,  as 
belonging  to  the  second  class:  the  author  so  treats  them  because, 
while  they  may  not  all  express  a  vice,  he  cannot  prove  that  they  do 
not.  By  treating  them  with  the  latitude  given  to  cancer,  nothing 
detrimental  to  an  innocent  growth  is  done,  but  everything  possible, 
with  our  present  knowledge,  should  the  disease  be  cancer.  This 
practice  the  writer  himself  shall  continue  to  pursue — finding  in  it  the 
commendation  of  his  highest  intelligence — until  the  typical  some- 
thing is  discovered  which  shall  allow  him  to  know  a  cancer  in  all  its 
expressions,  just  as  to-day  one  might  not  easily  be  deceived  in  the 
herniiB  or  ranul^. 

The  Epulides  not  Self-explaining. — We  pass  now  to  that 
consideration  which  includes  every  other  epulic  tumor  which  may 
be  met  with  in  the  mouth  :  histologically,  we  would  class  these  as 
myeloid,  sarcoid,  myxoid,  fibroid,  scirrhoid,  encephaloid,  etc. ;  clin- 
ically, we  are  not  concerned  to  give  them  any  name  :  the  single  con- 
cern with  our  classification  being  as  to  the  self-explainability  or  non- 
explainability  of  a  tumor.  With  the  epulides  the  author  has  had 
much  to  do ;  he  may  be  pardoned  for  suggesting  that  perhaps  few 
in  this  direction  have  had  wider  opportunities  of  observation;  and, 


826  ORAL  DISEASES  AND   SURGERY. 

as  the  result  of  such  an  experience,  he  believes  that  he  advances  the 
highest  truth,  and  that  which  will  be  found  to  redound  to  the  greatest 
good  of  a  patient,  when  he  teaches  that  that  is  to  be  called,  viewed, 
and  treated  as  cancer  which  cannot  he  proved  not  to  he  cancer."^ 

Cancer  is  treated  in  consideration  of  a  twofold  expression  belong- 
ing to  the  condition.  When  infiltrated,  that  is,  when  parts  adjacent 
to  a  tumor  seem  to  be  in  marked  sympathy,  being  engorged  and 
shading  dimly  away  into  the  healthy  structure ;  when  glands  are 
indurated  and  dyscrasia  is  marked  ;  then,  not  knowing  any  antidote 
to  the  virus,  a  surgeon  can  do  nothing  for  a  patient.  When,  on  the 
contrary,  a  cancer  expression  is  strictly  localized,  when  a  tumefaction 
does  not  shade  gradually  away,  but  possesses  a  strict  individuality, 
like  the  concentric  fibroid, — a  spindle-celled,  or  even  a  giant-celled, 
sarcoma, — then,  let  it  be  epulic,  or  wherever  situated,  ablation  is 
indorsed,  on  the  principle  of  assistance  rendered  to  a  something 
which  offers  its  highest  expression  of  attempt  to  help  itself. 

Thus,  accepting  the  premises,  we  are  to  fiud  in  the  character  of  an 
epulic  tumor  the  practice  pertaining  to  it.  It  would  seem  impossible 
for  indecision  or  confusion  to  exist;  only  may  it  pertain  to  the  con- 
science of  the  surgeon  to  be  certain  that  he  keeps  pace  with  the 
diagnostic  intelligence  of  his  age. 

Presenting  Figs.  252-256  as  illustrations  of  some  of  the  various 
expressions  of  the  epulides,  attention  may  be  directed,  with  benefit 
to  many,  perhaps,  to  a  description  of  the  cases,  together  with  the 
practice  adopted,  and  the  results. 

Case,  J'ig.  252. — Some  four  years  ago,  Mrs.  T.,  the  sister  of  a 
medical  friend,  was  brought  by  her  brother  to  my  office  for  consultation 
on  a  tumor  (about  the  size  of  an  ordinary  pea)  growing  from  the 
alveolus  of  an  upper  molar  tooth.  I  thought  this  tumor  belonged 
to  the  class  pulp-fungoid.  There  was  the  broken  palatine  fang  in 
the  jaw,  but  so  deep  as  to  be  only  fairly  discernible  to  the  probe ;  I 
could  not  see  the  origin  of  the  growth,  but  inferred  its  character; 

*  The  author  of  course  sees  that  here  are  involved  the  learning,  experi- 
ence, and  judgment  of  an  observer.  But  with  all  grades  of  experience,  he 
must  perceive  his  position  equally  to  hold.  A  man  can  handle  and  treat 
a  matter  only  as  he  comprehends  it ;  it  is  the  fatal  misfortune  of  all  cancer- 
atHicted  patients  that  the  highest  intelligence  has  not  yet  arrived  at  the 
apprehension  of  what  cancer  is.  It  is  a  great  misfortune  for  a  patient  to  fall 
into  the  hands  of  a  practitioner  who  does  not  know — to  the  extent  of  the 
known — what  is  not  cancer. 


TUMORS   OF   THE  MOUTH. 


827 


and,  by  separating  carefully  the  alveolus  from  the  fang,  I  was  en- 
abled, after  some  little  trouble,  to  get  the  root  from  its  bed.     The 


Epulic  Tumors. 


Fig.  252. 


Fio.  2")4a. 


Fig.  253. 


Fig.  254  6. 


Fig.  255. 


Fig.  256. 


little  tumor  proved  to  be  an  outgrowth  of  the  periodonteal  membrane, 
and  not  au  excrescence  from  the  pulp  ;  in  character  it  was  distinctly 


828  ORAL  DISEASES  AND  SURGEBY. 

and  decidedly  fibrous, — it  was,  then,  histologically  classifiable  as  an 
epulo-fibroid  tumor.  It  did  not  look  like  a  growth  from  the  periodon- 
teum,  but  rather  as  if  its  origin  was  in  the  crusta  petrosa,  and  it  had 
carried  the  membrane  before  it,  somewhat  as  the  infundibuliform 
fascia  is  made  a  tunic  to  the  descending  intestine  in  an  oblique  inguinal 
hernia.  The  removal  of  the  fang  brought  the  growth  cleanly  away. 
Of  course,  no  scraping  or  cutting  of  the  parts  was  necessary :  the 
growth  was  evidently  an  emanation  of  the  dental  aspect  of  the 
periodonteum,  and  had  in  no  way  involved  its  alveolar  reflection. 
No  treatment  of  any  kind  outside  of  the  removal  of  the  tooth  was 
employed.  The  patient  remains  perfectly  cured.  This  is  the  only 
growth  of  just  such  relations  that  I  have  ever  met  with. 

Case,  Fig.  253.  Epiilo- Erectile  Tumor. — Mrs.  J.  presented  herself 
some  time  in  1862,  with  a  livid,  threatening-looking  tumor,  the  size 
of  a  hickory-nut,  occupying  the  left  alveolar  face  of  the  upper  jaw, 
extending  from  the  lateral  incisor  back  to  near  the  tuberosity.  This 
tumor  diminished  in  size  during  sleep,  and  increased  during  the 
time  of  any  excitement  which  tended  to  accelerate  the  circulation, 
sometimes  seeming  like  a  solid  body,  at  other  times  like  a  spongy 
mass ;  it  was  evidently  erectile  in  its  nature,  analogous  to  the 
ordinary  ngevi.     It  was  an  epulo-erectile  tumor. 

Separating  the  growth  from  the  gum,  its  association  with  the 
periosteum  was  plainly  evident;  and  the  probe  revealed  extensive 
involvement  of  the  neighboring  bone.  An  operation,  which  resulted 
in  complete  cure,  was  performed  as  follows:  the  lip  being  held  well 
out  of  the  way  by  an  assistant,  an  incision  was  made,  extending 
from  the  central  incisor  tooth  of  the  affected  side  back  to  the  tuber- 
osity, a  similar  cut  being  carried  back  on  the  palatine  face  of  the 
tumor  to  the  place  of  beginning  :  these  cuts  were  made  freely  through 
the  soft  parts  down  to  the  bone,  and  completely  circumscribed  the 
tumor,  with  a  reasonable  margin  to  spare.  The  central  incisor  was 
next  extracted,  and,  with  the  ordinary  cutting-forceps,  a  cut  was 
made  through  its  alveolus,  extending  almost  to  the  labio-nasal  angle. 
A  second  pair  of  cutting-forceps  was  now  taken  up,  and,  by  two  cuts 
the  width  of  its  blades,  the  involved  bone  was  removed  ;  the  section 
extending,  as  is  evident,  from  the  situation  of  the  left  central  incisor 
to  the  tuberosity.  Considerable  hemorrhage  attended  the  operation, 
although  the  section  was  well  outside  of  the  vessels  involved,  three 
ligatures  being  required.  Treatment  by  excision  of  the  bone  was 
here  necessitated  from  the  implication  of  that  tissue. 

After- Treatment. — The  lady  being  of  very  full  habit  and  of  mark- 


TUMORS   OF  THE  MOUTH.  829 

edly  sanguine  temperament,  magnesias  sulph.  ^ss  was  ordered  the 
evening  of  the  operation.     As  an  opiate,  morph.  sulph.  gr.  ss. 

Day  after  Operation. — Marked  inflammatory  action,  attended  with 
considerable  swelling  of  the  tissues  of  the  face. 

R. — Plumbi  acetatis,  5'j ; 
Tincturae  opii,  ^ij  ; 
Aquae,  §xvj. 

Ordered  a  cloth  wet  with  this  preparation  to  be  kept  continuously 
upon  the  face. 

Third  day.  Inflammation  increasing ;  eyes  completely  closed  from 
the  great  oedema  of  the  lids  ;  mag.  sulph.  reordered,  together  with 
hot  pediluvia;  eyelids  heavily  painted  with  tincture  of  iodine. 

Fourth  day.  Erysipelas  set  in  ;  the  face  looking  like  a  glistening 
red  ball ;  patient  restless,  nervous,  and  frightened ;  painted  the 
whole  face  with  tincture  of  iodine,  officinal  strength  ;  the  lead-water 
and  laudanum  continued  ;  iron  and  quinine  internally.* 

R. — Tincturae  ferri  chloridi,  5i'j  I 
Quini^  sulphatis,  gr.  xxv. 
Sig. — Fifteen  drops  in  water  every  three  hours. 

Also  a  diaphoretic : 

R. — Liquoris  ammoniae  acetatis,  ^ij. 
Sig. — Tablespoonful  every  ten  minutes  until  the  induction  of  pro- 
fuse perspiration. 

Sixth  day.  Erysipelas  evidently  yielding  ;  iron  and  quinine ;  paint- 
ing with  iodine,  lead-water,  and  laudanum,  continued. 

Seventh  day.  Much  improved  ;  the  erysipelatous  redness  gone  ; 
skin  wrinkling ;  patient  can  see  a  little  from  one  eye  ;  continued 
the  painting  with  the  iodine,  and  the  application  of  the  lead-water 
lotion. 

Ninth  day.  Inflammation  all  gone  ;  patient  quite  comfortable  ;  the 
exposed  bone  covered  with  a  thin  layer  of  healthy  granulations  ;  case 
progressing  well. 

Twelfth  day.  Patient  attending  to  household  duties  ;  mouth  of 
course  very  tender,  but  advancing  rapidly  toward  a  cure. 

*  The  author,  for  such  erysipelatous  inflammations,  now  always  employs 
for  local  use  the  combination  recommended  of  iron,  quinia,  and  cinchona. 


830  ORAL  DISEASES  AND   SURGERY. 

Tiventy-fifth  day.  Patient  may  be  called  well ;  needs  no  further 
attention. 

To  complete  the  case,  artificial  teeth  have  been  inserted,  the  plate 
being  made  to  fill  up  the  place  of  the  lost  bone.  No  one  would  ever 
suppose,  in  looking  at  the  lady,  that  she  had  lost  such  a  portion  of 
the  jaw.     At  this  writing  (1872)  the  patient  remains  cured. 

Case,  Figs.  254  a  and  254  h. — Recurring  epulo-fihrous  tumor. — 
These  two  views,  from  life,  represent  the  case  of  a  young  lady  as  an 
epulic  tumor  appeared  when  first  operated  on,  and  as  it  reappeared 
and  was  reoperated  on  some  four  months  after  the  first  operation. 

The  patient,  a  young  lady  of  much  more  than  ordinary  personal 
attraction,  applied  for  treatment  of  the  tumor  as  represented  in  the 
first  view.     The  necessity  for  an  operation  having  been  explained  to 
the  patient  and  her  parents,  I  made  the  following  suggestions.   First, 
that  a  section  be  made  which  should  simply  remove  the  tumor  and 
the  alveolar  process  connected  with  it.    If  this  should  succeed,  there 
would  be  no  deformity.     Second,  if  the  growth  should  reappear,  a 
second  operation  to  be  performed,  which  should  remove  the  bone 
proper,  except  a  simple  rim  of  continuity.    Third,  if  this,  too,  should 
fail,  then  the  complete  section  of  the  bone  to   be   made ;  this,  of 
course,  would  be  deforming,  but  it  would  be  the  only  resource. 
In  December,  ISGG,  the  first  of  the  operations  was  performed ;  the 
bone   outside   the  section  looked  perfectly 
Fig.  2.')7.  healthy,  and  gave  every  promise  of  a  satis- 

factory result.  In  two  weeks  healthy  granu- 
lations had  covered  the  bone,  and  in  one 
month  the  patient  was  dismissed  cured. 
The  following  March,  however,  a  small  tu- 

Section  of  bone  as  first  and        ,  ■,  •,     •        ,i  .  /<    xi 

afterward  made.  ^ercle  appeared  in  the  very  centre  of  the 

site  of  the  original  tumor,  and  in  the  course 
of  three  weeks  half  a  dozen  new  tumors  or  lobules  had  sprung  up. 
The  second  operation,  as  proposed,  was  now  performed,  the  con- 
tinuity and  natural  arch  of  the  bone  being  preserved  unbroken. 
This  was  successful.  The  patient  now  (1872)  remains  perfectly 
well.  The  site  of  the  removed  bone  is  occupied  by  artificial  teeth  ; 
and  not  the  slightest  deformity  is  to  be  observed. 

Fig.  255. — This  figure  exhibits  a  case  operated  on  in  1836  by  the 
celebrated  English  surgeon  Mr.  Liston.  The  following  is  a  sum- 
mary of  it,  given  by  that  gentleman  in  a  paper  on  "  The  Tumors  of 
the  Jaws  :" 


J 


TUMORS  OF  THE  MOUTH.  831 

"The  patient  had  labored  under  the  disease  for  eight  years,  and 
had  been  subject  to  a  partial  removal  of  the  growth  when  of  in- 
considerable size.  The  tumor  was  of  Gbrous  nature  as  regards  its 
disposition,  form,  and  intimate  structure.  It  differed  somewhat,  how- 
ever, in  outward  appearance,  in  consequence  of  its  exposed  situation. 
The  growth  sprang  originally  from  the  gums  and  sockets  of  the  in- 
cisors and  canine  teeth  of  the  left  side  ;  at  an  early  period  it  pro- 
truded from  the  mouth,  unconfined  and  uninfluenced  by  the  pressure 
of  the  lips  or  cheek.  It  had  assumed  a  most  formidable  size  and 
appearance,  concealed  the  palate  and  pharynx,  and  gave  rise  to 
great  inconvenience  and  suffering.  The  surface  had  been  broken 
by  ulceration,  but  upon  close  inspection  of  the  projecting  part,  and 
of  that  covered  by  the  cheek,  it  was  found  to  possess  a  firm  consist- 
ence, and  to  present  a  peculiar  botryoidal  arrangement  of  its  parts. 

"An  operation  proved  perfectly  successful." 

Case  —  not  illustrated.  —  Mrs.  S.,  of  Camden,  N.  J.;  epulo- 
fibroid  tumor  of  left  superior  jaw.  This  growth  was  the  size  of  a 
large  walnut,  the  bulging  of  the  cheek  quite  deforming  the  patient; 
growing  very  rapidly ;  painless.  Patient  had  been  confined  with  her 
fourth  child  five  weeks  before  presenting  herself. 

0];)eration. — This  was  performed  three  weeks  later.  The  tumor, 
or  all  that  portion  of  it  which  was  free  of  the  bone,  was  cleanly 
removed  with  the  scalpel,  together  WMth  a  margin  of  surrounding 
healthy  tissue.  This  step  exposed  the  bone,  which  was  found 
carious.  This  was  to  be  removed,  which  was  easily  effected  by  the 
use  of  the  gouge,  little  by  little  being  cut  away  until  healthy  struc- 
ture was  exposed.  The  surgeon  recognizes  such  healthy  structure 
both  by  its  feel  under  the  instrument  and  by  its  appearance  ;  healthy 
living  bone  being  white,  studded  with  minute  bleeding  points. 
Hemorrhage  during  the  operation  was  considerable,  but  was  con- 
trolled, without  ligature,  by  throwing  alum-water  into  the  wound 
from  an  ordinary  syringe. 

After- Treatment. — Very  little  required;  a  w^ash  of  the  perman- 
ganate of  potash,  five  grains  to  the  ounce  of  water,  was  given  as  a 
disinfectant,  there  being  for  a  few  days  a  somewhat  disagreeable 
odor  from  a  decomposing  blood-clot.  No  antiphlogistic  or  systemic 
treatment  of  any  kind  was  required,  not  a  bad  symptom  having  ap- 
peared, the  patient  being  entirely  well  three  weeks  after  the  day 
of  operation.  In  this  case  the  floor  of  the  antrum  was  removed  and 
the  cavity  wholly  exposed.  At  the  completion  of  the  cure,  it  was, 
however,  closed  up. 


832  ORAL  DISEASES  AND  SUBGERY. 

Case — not  illustrated. — Mrs.  T.,  West  Chestnut  Street.  Tumor 
of  four  years'  growth  ;  loose  in  structure,  occupying  one-half  of  the 
roof  of  the  mouth,  giving  a  most  disgusting  and  threatening  appear- 
ance. The  growth  had  first  appeared  between  the  bicuspid  and  first 
molar  teeth,  and  at  the  time  of  my  first  seeing  it  had  entirely  de- 
stroyed the  inner  alveolar  plate  of  all  the  portion  of  the  jaw  with 
which  it  was  associated.  In  raising  the  tumor  from  its  bed,  all  the 
underlying  palatine  process,  so  far  as  could  be  seen,  was  found  to  be 
diseased. 

Operation. — This  consisted  in  cutting  away  with  the  scalpel  as 
much  of  the  growth  as  possible,  and  completing  the  operation  on  the 
bone  with  the  gouge;  hemorrhage  very  profuse,  the  use  of  a  com- 
press being  necessary  for  its  arrestation,  and  this  only  effected  after 
several  hours. 

After-  Treatment. — Very  little  required  ;  some  over-inflammatory 
action,  which  quickly  and  readily  yielded  to  low  diet  for  a  few 
days,  and  a  single  dose  of  sulphate  of  magnesia.  In  three  weeks 
the  case  was  in  condition  to  be  dismissed. 

These  special  illustrations,  all  of  them,  with  the  exception  of  the 
third,  being  without  the  pale  of  our  first  classification,  are  given 
because  they  serve  to  show  that  there  is  an  order  of  fibrous  tumors ; 
or,  on  the  other  hand,  an  antagonizing  condition  of  the  system, 
which,  fully  appreciated,  would  afford  to  the  surgeon  an  ability  to 
prognose  the  result  of  operations  on  them  with  the  same  certainty 
as  in  the  removal  of  a  pulp-fungoid.  To  be  able  to  distinguish  this 
class,  or  species,  or  condition,  would  certainly  signifj-  a  step  gained, 
— one  of  the  many  steps  to  be  made,  without  doubt,  by  those  who 
shall  come  after  us.  But  such  ability  to  distinguish  does  not  yet 
exist.     We  may  infer,  but  we  cannot  be  certain. 


CHAPTER    XL. 


THE    TUMORS   OP   THE    MOUTH. 


EXOSTOSIS  AND  SUBACUTE  INFLAMMATOKY  TUMOKS. 

The  term  exostosis,  as  the  reader  will  remember,  is  derived  from 
the  Greek  words  sS,  "out  of,"  and  orr-so-^,  a  "bone:"  it  denotes  an 
osseous  tumor  which  forms  at  the  surface  of  bones,  or  in  their  cavi- 
ties ;  the  first  is  called  exostosis,  the  latter  enostosis. 

The  following  varieties  have  been  named  :  "Ivory  exostosis,  that 
which  is  ivory-like;"  lamina  exostosis,  that  which  is  made  up  of 
distinct  fibres  or  layers ;  spongy  exostosis,  that  which  is  like  the 
spongy  tissue  of  bone. 

Hyperostosis  is  precisely  the  same  thing  as  exostosis,  both  being 
inflammatory  hypertrophies.  Inflammatory  osseous  tumors  are 
hyperostoses. 

Because,  however,  there  are  great  differences  in  the  expressions  of 
these  conditions,  I  shall  write  of  them  under  special  heads. 

Exostosis,  as  commonly  met  with  in  the  mouth,  is  strictly  benign. 
It  is  generally  recognizable  by  its  extreme  slowness  of  growth,  the 
entire  absence  of  pain, — except  when  it  meets  with  some  peculiar 
obstruction, — and  its  freedom  from  surrounding  disease.  It  does  not 
tend  markedly  to  ulceration,  and  does  not,  except  mechanically,  affect 
the  parts  even  most  directly  associated  with  it. 

True  exostosis  has  its  origin  in  local  irritation,  perhaps  always. 
It  is  true  that  reference  is  made  by  authors  to  an  ossific  diathesis,  but, 
as  is  truly  remarked  by  Miller,  "A  skeleton  so  susceptible  is  prone 
rather  to  the  more  common  inflammatory  products  of  caries,  abscesses, 
ulcers,  and  necrosis." 

That  local  irritation  is  the  chief  cause  of  exostosis  is  satisfactorily 
proven,  I  think,  by  reference  to  parts  most  subject  to  this  interfer- 
ence. The  teeth,  for  example,  are  found  exostosed  in  a  thousand 
instances  to  one  of  any  other  bone,  and  certainly  no  bones  are  so 

52  '         ( 833 ) 


834  ORAL  DISEASES  AND  SURGERY. 

constantly  found  in  irritative  conditions.  I  use  the  term  "bone," 
reminding  the  reader  that  the  portion  of  the  tooth  which  takes  on 
this  morbid  action  is  almost  in  every  proper  sense  true  bone. 

Non-specific  exostosis,  occurring  on  any  portion  of  the  maxillary 
bones  removed  from  the  alveolar  borders,  is  an  exceedingly  infrequent 
affection.  With  every  opportunity  for  observation,  I  am  surprised 
at  the  fewness  of  the  cases  I  have  seen  ;  and  these,  with  a  very  few 
exceptions,  have  been  small,  and  of  little  consequence. 

Around  the  base  of  the  alveolar  processes,  however,  and  particu- 
larly on  the  lingual  aspect  of  the  lower  jaw,  this  affection,  in  a  minor 
form,  is  exceedingly  common;  certainly  I  have  seen  hundreds  of 
examples,  the  enlargements  varying  from  the  size  of  a  small  shot  to 
that  of  a  rifle-ball.  As  pathological  relations  are  concerned,  they 
seem  of  little  consequence  ;  I  never  knew  one  to  result  in  any  harm  ; 
and  the  treatment  I  have  adopted  in  such  cases  has  been  coaimonly 
the  very  simple  one  of  letting  them  alone. 

It  is  Jiot  improbable,  though,  that  cases  may  present  when  opera- 
tions seem  demanded.  I  have  felt  called  to  operate  upon  some  two 
or  three  of  such  as  I  have  met  w^ith.  The  mode  of  procedure  is 
simply  to  lay  off  from  the  tumor  the  soft  parts,  and,  with  a  chisel, 
cut  away  the  mass ;  there  is  no  hemorrhage  or  other  trouble  attend- 
ant on  the  operation.     (See  Hyperostosii<.) 

Exostosis  of  the  fangs  of  the  teeth — exostosis  dentium,  the  usual 
seat  of  the  disease  in  the  maxillary  regions — finds  location  both  in 
the  cemental  and  dentinal  structures  of  these  organs ;  for  while  I 
have  seen  two  or  three  cases  where  the  crowns  of  the  teeth  were 
enlarged,  as  if  from  a  species  of  exostosis  or  hypertrophy,  yet  these 
were  so  anomalous  that  I  may  describe  the  growth  as  being  asso- 
ciated exclusively  with  the  fangs  ;  and  even  here,  I  think,  it  will  be 
found  in  the  majority  of  instances  confined  mostly  to  the  apex, 
growing,  bulb-like,  as  it  were,  about  the  end  of  the  root. 

The  diagnosis  of  exostosis  in  these  situations  is  not  always  with- 
out confusion.  The  most  frequent  pathognomonic  feature,  however, 
is  a  sense  of  continued  uneasiness  about  the  parts,  not  generally 
amounting  to  pain,  but  serving  as  a  constant  reminder  of  the  pres- 
ence of  the  tooth.  The  tooth  itself  may  or  may  not  be  carious. 
Pressure,  or  the  stroke  of  an  instrument,  does  not,  in  ordinary  cases, 
either  increase  or  diminish  the  soreness;  the  sense  of  fullness  about 
the  parts  is  particularly  observed  where  the  absorption  of  the  alveo- 
lus is  not  proportionably  active  with  the  exostosis.  In  these  latter 
cases,  the  extremest  symptoms  of  neuralgia  are  not  unfrequently 


TUMORS  OF  THE  MOUTH.  835 

produced,  and,  if  not  comprehended,  are  of  course  treated  without 
avail. 

One  of  the  most  remarkable  cases  of  dental  exostosis  on  record  is 
related  by  Mr.  Fox.  The  subject  was  a  young  lady,  who,  at  the 
time  she  sought  the  professional  aid  and  advice  of  this  practitioner, ' 
had  suflfered  so  severely  and  so  long  that  the  palpebrae  of  one  eye 
had  been  closed  for  nearly  two  months,  and  the  secretion  of  saliva 
had  for  some  time  been  so  copious  as  to  flow  from  her  mouth 
whenever  it  was  opened.  She  had  tried  every  remedy  which  had 
been  recommended  by  the  ablest  professional  advisers,  without  de- 
riving any  permanent  benefit,  and  was  only  relieved  by  the  extraction 
of  every  one  of  her  teeth. 

The  surgeon  may  infer  from  the  mention  of  this  case  that  he  is 
likely  to  meet  with  many  gradations  of  the  trouble.  The  cure  will 
consist  in  the  removal  of  the  affected  member:  this,  after  the  diag- 
nosis, is  always  easily  accomplished  with  the  aid  of  a  pair  of  cutting- 
forceps. 

Warty  Teeth. — In  this  association  reference  may  be  made  to  an 
anomalous  confusion  and  development  of  teeth-germs  to  which  the 
term  warty  has  been  applied.  Upon  another  page  we  shall  discuss 
them  under  the  aspect  of  dentigerous  cysts.  The  rarity  of  these 
warty  teeth  permits  few  the  opportunity  of  seeing  them.  Among 
the  recorded  examples  are  four  by  S.  J.  A.  Salter,  one  by  Mr.  John 
Tomes,  two  by  Wedl,  two  by  M.  Oudet,  two  by  M.  Forget,  and 
one  by  Mr.  Harrison. 

To  teeth  of  such  anomalous  development  M.  Broces  has  applied 
a  name  that  has  now  come  into  general  use,  namely,  odontomata. 
These  he.  with  all  propriety  and  clinical  justice,  has  classified  into 
circumscribed  and  diffused, — the  first  including  all  masses  in  which 
recognition  of  the  tooth  exists  ;  the  second,  those  where  it  is  lost 
in  an  anatomical    confusion  of  the   structures.  pj^.  9-g 

The  odontoma  described  from  the  practice  of 
M.  Forget,  on  a  succeeding  page,  constitutes 
the  most  marked  example  of  the  latter  on  record. 
Fig.  258  is  an  example  of  the  former.  Examples 
of  the  circumscribed  odontomata  are  given  on 
Plate  I.,  Subfigs.  1  and  3. 

A  form  of  dental   exostosis  termed   by  Mr. 
Salter  the  enamel  nodule  exhibits  a  pearl-like  odontc.mii. 

excrescence  growing  from  a  tooth.  Excrescences  of  this  kind  are 
considered  to  be  essentially  submerged  cusps,  being  composed  of  a 
cone  of  dentine  enveloped  by  a  cap  of  enamel. 


836 


ORAL  DISEASES  AND   SURGERY. 


Fig. 


As  au  illustration  of  extreme  dental  hypertrophy,  combined  with 
the  existence  of  an  enamel  nodule,  attention  may  be  directed  to  a 
specimen  belonging  to  the  Philadelphia  Dental 
College,  exhibited  in  Fig.  259.  This  mass  is  two 
and  a  half  inches  in  length  by  two  and  five-eighths 
inches  in  circumference;  it  was  associated  with  the 
roots  of  a  left  superior  molar,  and  was  extracted 
from  the  mouth  of  a  laborer  by  S.  H.  Whitman, 
of  Newport,  Perry  County,  Pennsylvania. 

In  examining  this  specimen,  it  is  observed  that 
to  the  right  of  the  palatine  root,  and  connected 
with   it,  is  a  portion  of  enamel ;  being  an  out- 
growth, as  has  been  inferred,  either  of  a  wisdom 
or  of  a  supernumerary  tooth, — most  likely,  how- 
ever, a  production  of  the  tunica  propria  of  the  tooth  itself     Mr. 
Salter  describes    such   cusps  as   being  clothed   with   a  pulp, — the 
enamel  pulp. 

A  microscopical  section  of  this  growth  is  figured  (Fig.  260) 
and  described  by  my  friend  Dr.  J.  H.  McQuillen,  through  whom,  I 
believe,  the  specimen  was  received  by  the  museum: 

"A  first  or  outer  section  presented  only  the  lacunae  and  canaliculi 
characteristic  of  cementum.     A  second  cut  differed  somewhat  from 

this,  in  having,  in  addition,  certain 
spaces  of  no  definite  shape,  and  ap- 
parently being  the  blending  of  a 
number  of  the  lacunae.  In  a  third 
section  the  lacunae  were  quite  numer- 
ous, and  the  canaliculi  starting  from 
them  were  of  considerable  length, 
and  pursued  a  tortuous  or  curved 
direction,  resembling  very  much  the 
appearance  and  course  taken  by  the 
dentinal  tubuli  in  secondary  dentine. 
Fig.  260  is  from  a  drawing  as  seen 
under  the  microscope.  A  few  canals 
(cut  transversely),  evidently  for  the  passage  of  blood-vessels,  were 
observed,  but  no  Haversian  canals,  as  in  bone,  with  the  lacunae  and 
canaliculi  arranged  in  concentric  layers  around  them." 


In  the  venereal,  scorbutic,  and  tubercular  hypertrophies  or  exos- 
toses of  the  maxillary  bones,  the  features  of  the  common  disease 


TUMORS   OF  THE  MOUTH.  837 

become  quickly  evident  m  the  local  trouble  ;  so  remarkably  so, 
indeed,  that  no  one  would  be  likely  to  misunderstand  things,  pre- 
supposing the  general  disease  to  be  understood.  The  growths 
are  rapid,  painful,  and  almost  always  more  or  less  amenable  to  con- 
stitutional treatment. 

Scrofulous  and  scorbutic  tumors  differ  from  the  venereal  in  being 
more  loose  and  spongy  in  structure,  and,  in  consequence,  more  apt 
to  run  into  abscess,  being  possessed,  as  it  were,  of  elements  for  their 
own  destruction. 

In  these  forms  of  maxillary  disease,  the  lesion  is  commonly 
heralded  by  deep-seated,  dull  pains,  which  precede  by  some  time 
the  visible  enlargement  of  the  part.  After  the  tumefactive  process 
sets  in,  it  goes  on,  if  uncombated,  until  the  parietes  of  the  bone 
are  completely  disparted.  Associated  with  this  enlargement  is  an 
unhealthy  condition  of  the  soft  parts. 

As  the  disease  advances,  the  centre  of  the  tumor  softens,  while 
the  character  of  the  pain  changes,  becoming  sharp  and  throbbing  ; 
as  pus  forms,  sinuses  are  created,  and  thus  ulcerations  occur  on  the 
face  of  the  tumor.  Enlargement  of  the  maxillae  from  these  causes 
is,  however,  very  uncommon,  and  might  only  escape  being  con- 
founded with  cancer  by  observation  of  the  association  with  the 
disease  at  large. 

The  treatment  of  inflammatory  tumors  of  these  and  similar  types 
is  to  be  conducted  in  consideration  of  their  twofold  requirements. 
The  systemic  influences  are  to  be  corrected,  while,  locally,  I  think  I 
am  justified  in  asserting  that,  as  a  rule,  they  will  succumb  to  the 
treatment  commonly  directed  against  similar  abscesses  of  the  soft 
parts.  I  have  great  confidence  in  the  use  of  tents  and  stimulating 
injections. 

Thei'e  is  a  simple  inflammatory  tumefaction  of  the  maxilla  some- 
times met  with,  which  might  be  mistaken  for  specific  exostosis. 
It  is  to  be  distinguished,  hov/ever,  by  the  greater  rapidity  of  the 
swelling  and  by  the  greater  soreness  attendant  on  it;  it  comes 
as  a  cold  in  the  head,  or  on  the  chest, — without,  in  the  majority 
of  cases,  the  patient  being  able  to  assign  any  cause, — and  it  is 
found  soon  to  give  way  to  the  same  class  of  antiphlogistics.  This 
tumefaction  is  extra-  rather  than  intramaxillary ;  it  is  simply  a  peri- 
osteal exudate,  and  has,  of  course,  no  constitutional  associative  lesion. 

In  this  connection,  attention  may  be  directed  to  a  form  of  tumor 
frequently  found  in  the  mouth,  which,  clinically,  is  classible  with 
the   exostoses.     I   allude    to   an    apparent  expansion   of  bone  fre- 


838  ORAL  DISEASES  AND   SURGERY. 

quently  found  in  association  with  a  strumous  diathesis,  and  so  in- 
variably in  connection  with  periodonteally  diseased  teeth  or  roots 
of  teeth ;  not  always,  however,  are  these  expansions  or  growths  in 
association  with  the  strumous  condition,  as  I  have  treated  them  in 
individuals  whose  constitutional  condition  seemed  perfect. 

These  tumors  have  a  common  history.  The  nerve  of  a  tooth  dies, 
and  the  periodonteum  takes  on  a  chronic  irritative  condition,  or  per- 
haps a  tooth  has  been  fractured  in  attempts  at  extraction,  and  the 
root,  or  some  portion,  has  been  left  in  the  socket.  After  a  time, 
sooner  or  later,  a  slight  swelling,  apparently  of  the  gum,  is  ob- 
served. This  may  readily  be  taken  for  a  chronic  alveolar  abscess  ; 
there  is  no  pain,  however,  associated  with  the  enlargement,  which 
is  soon  seen  to  differ  from  the  abscess  in  the  slowness  of  its 
evolution ;  it  is  also  hard,  and  perfectly  unyielding  under  pressure. 
As  we  watch  the  case,  month  after  month,  we  find  it  gradually 
to  grow,  giving  to  the  observer  the  impression  of  an  expansion  of 
the  bone  under  the  gums,  although,  as  we  understand,  there  are 
no  special  or  marked  signs  of  such  cystiform  condition.  If  we  pass 
an  exploriug-needle  into  the  tumor,  it  feels  as  if  it  were  cutting  its 
way  through  spongy  bone ;  and  so  indeed  it  is,  as  dissection  will 
reveal  to  us  that  the  cancellated  structure  has  taken  on  hyper- 
trophic action,  and  it  is  such  spongy  enlargement  that  bulges  out 
the  overlying  parts  and  makes  the  tumor.  I  have  treated  quite  a 
number  of  these  growths,  and  invariably  in  connection  with  the  in- 
ferior jaw.  I  do  not  think  they  would  often  be  found  in  the  superior, 
such  chronic  conditions  being  here  more  apt  to  induce  caries,  which 
disease  we  know  to  be  as  uncommon  to  the  lower  as  it  is  common 
to  the  upper  jaw.  These  tumors,  so  far  as  I  have  seen  them,  either 
remain  fixed  in  character,  after  growing  to  the  size  of  half  a  walnut, 
or,  in  ver}^  bad  subjects,  they  degenerate  into  abscess,  and,  dis- 
charging thus  the  offending  body,  cure  themselves.  Such  sponta- 
neous cure  is,  however,  not  common. 

The  surgical  treatment  of  these  tumors  is  both  simple  and 
effectual.  It  is  enough,  not  unfrequently,  to  remove  the  tooth  or 
root,  particularly  if,  in  connection  with  such  removal,  we  keep  the 
socket  open  for  a  few  weeks  with  a  tent  of  cotton  or  sponge.  A 
very  certain  method,  and  one  which  I  am  in  the  habit  of  employing 
in  my  own  practice,  consists  in  cutting  away,  with  a  delicate 
gouge,  the  enlarged  mass  :  this  is  easily  accomplished  by  using  the 
opening  made  in  the  extraction  of  the  tooth  as  a  means  of  ingress  to 
the  mass  ;  it  can  in  this  way  be  cut  out,  piece  by  piece,  without  any 


TUMORS   OF   THE  MOUTH. 


539 


external  incision,  and  with  a  wound  not  larger  than  that  made  by 
the  preliminary  extraction.  After  such  operation  the  parts  are  to 
be  well  syringed,  and  a  tent  kept  in  the  tooth-socket,  to  insure 
granulations  from  the  circumference  of  the  wound.  In  two  or  three 
weeks  the  cure  will  commonly  be  found  complete. 

In  this  connection  attention  may  be  directed  to  an  obscurity 
which  sometimes  exists  in  the  diagnostic  relationship  of  diseased 
teeth, — that  is,  no  teeth  or  roots  of  teeth  may  seem  to  be  present. 
A  sufficiently  close  observation,  however,  will  always  detect  in  the 
neighborhood  a  fistulous  opening  ;  it  may  be  very  minute,  but  it  is 
seldom,  if  ever,  absent.  If  a  probe  be  passed  into  this  orifice,  it  will 
lead  to  the  ofifeudina,-  ag-ent. 


Fig.  261. — Hyfkrostosis. 


HYPEKOSTOSIS. 

In  connection  with  the  simple  tumors,  reference  may  now  be 
made  to  general  facial  hyperostosis  sometimes  existing.  In  a 
work  published  by  Mr.  Heath,  being  the  Jacksonian  prize  essay  for 
1867  of  the  Royal  College  of  Surgeons,  England,  the  following 
illustrative  diagram  and  description  of  a  case  are  given: 

The  patient,  when  about  forty-five  years  of  age,  and  apparently  in 
perfect  health,  was  exposed  to  a  cold  wind  ;  immediately  after  which 
he  perceived  an  itching  and  heat  in  his  eyes,  and  swelling  of  the 
face  rapidly  supervened.  A  small  tumor  formed  just  below  the 
inner  angle  of  each  eye,  which  burst, 
and  after  twelve  weeks  he  was  able 
to  resume  his  employment.  He  suf- 
fered from  inflammatory  attacks  in 
the  tumors,  with  much  pain  in  the 
head  on  more  than  one  occasion,  and 
consulted  many  medical  men ;  but 
no  treatment  relieved  the  disease  or 
retarded  the  growth  of  the  tumors, 
which  increased  slowly  and  were  of 
stony  hardness.  The  eyes  were  pro- 
jected from  the  orbits  by  the  tumors, 
and  th^  right  eye  inflamed  and  burst, 
while  the  left  was  accidentally  rup- 
tured by  a  blow.     The  patient  lived 

to  over  sixty  years  of  age,  and  died  of  apoplexy,  having  been  occa- 
sionally maniacal  during  the  last  two  years  of  life.  The  portrait  is 
taken  from  the  work  of  Mr.  Howship  ("  Practical  Observations  on 


840  ORAL  DISEASES  AND   SUBGERY. 

Surgery").  The  skull  of  the  patient  is  preserved  in  the  College  of 
Surgeons,  and  shows,  as  might  be  anticipated  from  the  portrait,  two 
large  masses  of  almost  exactly  symmetrical  form  and  arrangement, 
which  have  partially  coalesced  in  the  median  line.  The  growths  are 
as  hard  as  ivory,  and  consist  of  very  close,  cancellous  structure. 
They  project  more  than  three  inches  from  the  face,  and  an  inch  be- 
yond the  malar  bones  on  each  side.  The  man  attributed  the  growths 
to  repeated  blows  received  on  the  face  in  fighting. 

The  skull  of  a  Peruvian  (3093,  College  of  Surgeons,  London)  is 
also  alluded  to  by  this  same  author.  In  this  case  the  disease  is  of 
a  more  diffused  character,  all  the  bones  of  the  face,  as  well  as  the 
frontal  and  the  adjacent  parts  of  the  sphenoid  and  parietal,  being 
enlarged  and  thickened  in  a  remarkable  manner.  The  nasal  fossae 
and  orbits  are  nearly  closed,  the  superior  maxillary  bones  having 
grown  into  great  knobbed  and  tubercular  masses,  in  which  their 
original  form  can  hardly  be  discovered.  The  hard  palate  is  similarly 
diseased.  The  lower  jaw  is  enormously  enlarged  at  its  right  angle, 
and  in  the  greater  part  of  its  right  half  it  measures  upwards  of  five 
inches  in  circumference,  and  all  but  three  of  its  alveoli  are  closed  up. 
A  section  of  the  lower  jaw  shows  that  its  interior  is  composed  of  an 
almost  uniformly  hard  and  compact,  but  finely  porous,  bone.  There 
is  no  history  attached  to  the  specimen. 

Hyperostosis  is  simply  exostosis  or  enostosis.  It  is  analogous  to 
hypertrophy  of  the  soft  parts,  and  must  have  a  similar  history. 

As  can  be  very  well  understood,  varieties  in  form  and  character 
present  themselves.  These  growths  are  sometimes  associated  ex- 
clusively with  the  face  of  a  bone,  as  in  the  ordinary  exostosis.  In 
these  cases  the  periosteum  may  separate  the  two  bodies.  In  other 
cases  there  is  hypertrophy  of  the  bone  proper.  The  condition  is 
one  of  disease  only  as  there  is  a  lack  of  correspondence  in  other 
parts.  Any  section  of  a  hyperostosed  part  exhibits  the  peculiar 
features  of  bone-substance ;  it  may  be,  as  is  often  seen,  that  the 
cellular  substance  is  compressed  and  much  altered,  but  there  is  the 
distinction  to  be  observed  between  it  and  a  cortical  boundary,  and 
-'•the  analysis  remains  the  same, — that  is,  as  the  constituent  parts 
are  concerned.  When  these  hypertrophies  associate  exclusively 
with  the  endosteum,  as  in  long  bones,  they  obliterate  or  diminish 
the  medullary  canal,  and,  if  of  sufficient  size,  expand  the  external 
parts  into  a  tumor,  greater  or  less  in  size. 

The  history  of  any  form  of  hyperostosis  is  the  history  of  certain 
of  the   phenomena  of  inflammation ;  there  is,  from  some  cause  or 


TUMORS   OF   THE  MOUTH.  841 

other,  irritation  attended  with  vascular  changes,  the  effusion  of 
plastic  matter  associated  with  osseous  transformation.  What  this 
source  of  irritation  is,  and  how  to  control  it,  are  matters  which 
necessarily  invite  the  attention  of  the  surgeon. 

Reference  has  been  made  on  a  preceding  page  to  the  hypertro- 
phies of  the  specific  conditions  ;  such  enlargements  are  easy  enough 
to  understand,  even  if  not  so  easy  to  remove.  But  the  hyperostoses 
here  considered  are  not  of  such  character,  but  seem  to  be  of  an 
entirely  local  signification  ;  hence  a  local  source  of  offense  may  not 
be  sought  for  in  vain,  as,  for  example,  in  Mr.  Howship's  case, 
where  the  ostitis  might  very  plausibly  be  attributed  to  the  blows 
received.  The  inflammatory  thickening  of  bone,  alluded  to  a  few 
pages  back  in  connection  with  diseased  teeth-roots,  is  but  another 
exhibition  of  the  results  of  local  irritation. 

That  the  hyperostoses  are  to  be  viewed,  and  in  every  way  treated, 
as  simple  overgrowths,  is  certainly  well  exhibited  by  Mr.  Quekett, 
who,  submitting  to  microscopic  examination  portions  of  all  the 
osseous  tumors  in  the  Royal  College  of  Surgeons,  confirms  the 
position  in  all  particulars.  The  rates  of  the  growths  of  such 
tumors  are,  I  presume,  influenced  by  individual  susceptibilities  or 
peculiarities  ;  there  is  certainly  in  this  respect  the  greatest  possible 
difference.  In  the  Osteographia  of  Mr.  Cheselden  is  an  engraving 
of  an  osseous  tumor  surrounding  the  head  of  a  tibia,  which  measures 
exactly  one  yard  in  circumference.  An  imposing  growth  is  also 
figured  in  Mr.  Paget's  Surgical  Pathology. 

In  this  latter  case,  as  Prof.  Clark  describes  the  tumor,  the  hardest 
parts  have  neither  Haversian  canals  nor  lacunae.  In  the  less  hard 
parts  the  canals  are  very  large,  and  the  lacunae  are  not  arranged  in 
circles  around  them,  and  everywhere  the  lacunae  are  of  irregular  or 
distorted  form. 

A  remarkable  specimen  of  an  osseous  tumor  of  the  left  upper 
maxilla  (Fig.  262),  from  the  Traite  de  Pathologie  Externe,  found  in 
the  Musee  Dupuytren,  is  described  in  Mr.  Heath's  essay  as  being 
limited  behind  by  the  pterygoid  process,  internally  by  the  intermax- 
illary suture,  above  and  externally  by  the  malar  bone.  The  tumor<r 
encroaches  considerably  upon  the  cavity  of  the  mouth,  and  reaches 
back  as  far  as  the  front  of  the  spine.  Its  form  is  bilobcd,  and  in  the 
deep  sulcus  between  the  lobes  can  be  seen  a  molar  tooth.  All  the 
other  teeth  of  the  jaw  have  disappeared,  and  there  is  no  trace  of 
their  alveoli.     The  left  orbit  and  nasal  fossa  are  not  sensibly  dimiu- 


842 


ORAL  DISEASES  AND   SUBGERY. 


Fig.  2fi2. — Osseous  Tumor. 


ished  in  size,  but  the  cavity  of  the  mouth  is  almost  entirely  occupied 
by  the  posterior  lobe  of  the  tumor.     The  lower  jaw  has,  in  this 

case,  undergone  several  remarkable  alter- 
ations. It  must  at  first  have  pressed 
upon  the  growth  and  produced  the  deep 
sulcus  between  the  lobes  ;  but  in  its  turn 
the  tumor  has  reacted  upon  the  lower 
jaw  with  the  following  effect:  it  has 
caused  a  double  luxation  of  the  jaw,  the 
left  condyle  resting  against  the  root  of 
the  zygoma,  and  the  glenoid  cavity  being 
filled  with  soft  material.  The  teeth  of 
the  left  side  of  the  lower  jaw  have  disap- 
peared, and  absorption  of  part  of  the 
coronoid  process  and  the  whole  of  the 
alveolus  has  taken  place,  so  that  only  the  base  of  this  part  of  the 
bone  is  left.  The  outer  surface  of  the  tumor  is  smooth,  and  presents 
numerous  vascular  grooves  of  good  size  ;  at  many  points  it  is  per- 
forated with  holes.  The  vascularity  of  the  other  bones  of  the  face 
does  not  appear  to  be  augmented. 

In  Guy's  Hospital  Reports  a  case  is  described  by  Mr.  Hilton  in 
which  a  tumor  similar  in  signification  to  the  one  just  referred  to 
spontaneously  separated  from  the  face.  The  patient  was  a  man 
aged  thirty-six,  who,  twenty-three  years  before  Mr.  Hilton  saw  him, 
noticed  a  pimple  below  the  left  eye,  close  to  the  nose,  which  be  irri- 
tated, and  from  that  spot  the  tumor  appears  to  have  originated. 
The  tumor,  in  its  growth,  displaced  the  eyeball,  giving  rise  to 
excruciating  pain,  which  subsided  on  the  bursting  of  the  ball.  It 
began  to  loosen  by  a  process  of  ulceration  around  its  margin  six 
years  before  it  fell  out,  which  event  was  unattended  by  bleeding  or 
pain.  The.  tumor  weighed  fourteen  and  three-quarter  ounces.  It 
was  tuberculated  externally,  and  an  irregular  cavity  existed  at  the 
posterior  part.  A  section  presented  a  very  hard,  polished  surface, 
resembling  ivory,  and  exhibited  lines  in  concentric  curves,  enlarging 
as  they  were  traced  from  the  posterior  part.  The  huge  cavity  left 
by  the  tumor  was  bounded  below  by  the  floor  of  the  nose  and 
antrum,  above  by  the  frontal  and  ethmoid  bones,  internally  by  the 
septum  nasi,  and  externally  by  the  orbit,  which  had  been  consider- 
ably encroached  upon  by  the  tumor. 

Among  several  rare  arid  interesting  cases  in  this  direction,  which 
from  time  to  time  have  been  under  the  observation  of  the  author. 


TUMORS   OF  THE  MOUTH. 


843 


particular  mention  might  be  made  of  a  lad,  William  Mars,  born 
with  a  general  enlargement  of  the  whole  left  side  of  the  face, — 
cheek,  jaw,  teeth,  tongue.  As  the  boy  grows,  so  in  a  relative  pro- 
portion enlarges  the  left  side.  The  exact  mesian  line  of  distinction 
is  curious  to  observe:  the  left  side  of  the  tongue  is  quite  one-third 
larger  than  the  right,  the  papillae  likewise  showing  the  distinction. 
Commencing  with  the  left  central,  the  teeth  are  also  one-third  larger 
than  are  their  fellows  of  the  opposite  side.  The  ears,  also,  differ  in 
size.  No  sense  of  discomfort  is  experienced  by  the  patient.  This 
congenital  peculiarity  is  confined  strictly  to  the  head,  all  other  parts 
Ijeing  in  correspondence. 

The  cut  of  a  case  of  osseous  hypertrophy — being  the  exact  dupli- 
cate of  an  impression  in  plaster  in  my  own  possession,  taken  by  a 
practitioner  of  a  distant  county,  in  whose  own  mouth  the  tumor 
exists — is  kindly  sent  me  by  D.  H.  Goodwillie,  M.D.,  of  New  York, 
the  following  description  accompanying: 

Fig.  263. — Hyperostosis  of  Tuberosity  of  Maxilla. 


"  Osseous  Tumor  of  the  Bight  Superior  Maxillary. — Mrs.  B., 
aged  forty-four  years,  has  always  enjoyed  good  health.  About  six 
years  ago  she  noticed  that  the  alveolus  of  the  right  superior  maxil- 
lary began  to  enlarge,  and  has  gradually  increased  to  the  present 


844  ORAL   DISEASES  AND   SURGERY. 

time.  In  size  and  shape  it  very  much  resembles  a  hen's  egg,  the 
large  end  presenting  posteriorly.  It  extends  antero-posteriorly  from 
the  right  superior  canine  to  the  internal  pterygoid  process,  laterally 
from  near  the  centre  of  the  palate  to  the  maxillo-raalar  fossa,  for- 
ward to  the  canine  fossa,  and  to  a  slight  degree  into  the  antrum  of 
Highmore. 

"  The  mucous  membrane  over  the  surface  of  the  tumor  appeared  a 
Jittle  lighter  in  color  than  normal ;  this,  no  doubt,  was  due  to  the 
tension  on  it  by  the  parts  below.  In  the  surface  of  the  tumor  could 
be  seen  the  fangs  of  the  first  and  second  molars.  The  canine  and 
bicuspidati  were  not  decayed.  First  bicuspis  and  canine  retained 
their  normal  position  in  the  jaw,  but  their  crowns  were  somewhat 
buried  in  the  tumor.  The  crown  of  the  second  bicuspis  could  all 
be  seen  above  the  surface  of  the  tumor,  but  the  whole  tooth  was 
raised  out  of  its  natural  position,  and  thrown  inward  about  one- 
half  an  inch.  One  of  the  roots  of  a  molar  was  lying  longitudinally 
in  the  soft  parts  on  the  surface  of  the  tumor. 

"  She  has  experienced  no  pain,  or  discharge  from  the  mouth  or 
nose,  during  the  long  period  of  its  growth ;  from  its  apparent  firm 
texture,  together  with  the  excellent  health* the  patient  has  always 
enjoyed,  there  appears  no  doubt  of  its  benignant  character. 

"  Pathological  Appearances. — On  making  a  section  of  the  tumor 
through  the  longitudinal  direction  of  the  teeth,  there  was  to  be  seen 
the  following :  At  the  apex  of  the  second  molar  tooth  there  was  a 
small,  soft  cyst,  containing  some  pus,  and  for  a  short  distance  sur- 
rounding this  the  bone  appeared  quite  cancellated,  but  the  rest  of 
the  tumor  was  quite  dense  in  structure. 

"  The  pulp  of  the  canine  and  first  bicuspis  had  still  some  vitality, 
but  that  of  the  second  bicuspis  was  dead.  The  pulp-chambers  were 
decreased  in  size  by  a  deposit  of  osteo-dentine  to  their  walls,  slight 
hypertrophy  of  the  cementum  on  the  fangs.  A  large  nerve  entered 
the  tumor  on  its  buccal  side. 

"The  microscopical  examination  of  this  tumor,  as  made  by  Dr. 
J.  W.  S.  Arnold,  and  as  shown  by  his  drawing  (Fig.  264),  is  '  com- 
posed of  cancellated  tissue  almost  entirely  ;  the  outer  edge,  of  a  thin 
layer  of  more  compact  bony  tissue.  In  the  spongy  part  is  a  small 
amount  of  soft  marrow,  containing  the  usual  constituents  of  foetal 
marrow, — i.e.  medulla-cells,  and  myeloplaxes  with  oil-globules.'" 

Exostosis,  or,  more  correctly  speaking,  hypertrophy  of  the  tubes 
of  the  maxillary  bone,  is  a  quite  frequent  affection,  being  associated, 
as  the  author  infers,  with  the  continuous  excitability  engendered  in 


4 


TUMORS   OF   THE  MOUTH. 


845 


this  part  by  that  elongatory  process  which  terminates  only  in  adult 
life.     The  propriety  of  operating  upon  these  cases  is  to  be  cleter- 


FiG.  264. 


mined  by  the  individual  conditions.  Many  of  such  tumors  may 
safely  be  let  alone,  exhibiting  little  or  no  change  from  year  to  year. 
Associated  with  such  hypertrophies  the  author  has  met  with  neu- 
ralgia of  such  severity  that  only  through  section  of  the  affected 
part  could  relief  from  suffering  be  procured. 


CHAPTER    XL  I. 

THE    TUMORS    OP    THE    MOUTH. 

SELF-EXPLAINING  CYSTIC  TUMOKS. 

The  self-explaining:  cystic  tumors  of  the  jaws  are,  all  of  them 
dental :  of  this  the  author  is  now  entirely  satisfied.  In  the  former 
edition  of  this  work*  these  cysts  were  described  as  being  of  two  kinds, 
simple  and  compound  :  the  first,  the  simple  cysts,  were  alluded  to  as 
mere  expansions  of  the  outer  plate  of  the  bones, — wind-bags,  as  the 
older  writers  called  them.  The  second  class,  the  compound,  were 
described  as  cysts  containing  peculiar  contents,  which  contents 
induced  the  cysts  and  constituted  the  lesion  to  be  studied;  such  con- 
tents being  teeth  in  a  state  of  full  or  partial  or  anomalous  develop- 
ment, the  tumor  being  the  odontocele,  or,  as  it  might  as  well  be 
termed,  the  dentigerous  cyst. 

The  Simple  Cyst. — All  writers  on  surgery  have  remarked  the 
existence,  in  the  mouth,  of  this  form  of  tumor, — a  simple  expansion  of 
the  bone,  with  varying  fluid  or  gaseous  contents.  Different  authors 
differently  describe  and  name  them.  The  term  spina  ventosa  is, 
perhaps,  about  the  most  unmeaning  that  has  been  applied.  As  the 
author  knows  them,  their  history  ma}'  be  written  as  follows:  there 
is  first  remarked  on  the  side  of  the  jaw,  either  superior  or  inferior 
(no  preference  seems  to  exist),  a  slight  flattened  enlargement;  this 
increases  slowly,  until  the  swelling  reaches  the  size  of  half  a  hickoi'y- 
nut;  they  are  seldom  seen  larger.  No  pain  attends  the  growth, 
and,  outside  of  the  mental  disquietude  necessarily  induced,  no  func- 
tional or  other  constitutional  disturbance  attends.  The  slowness  of 
growth  is  such  that  it  may  require  from  one  to  three  years  to  reach 
the  size  alluded  to.  This  tardiness,  absence  of  pain,  and  constitu- 
tional disturbance  form  marked  diagnostic  signs.  Another  sign, 
and  one  on  which  most  writers  lay  particular  stress,  is  the  giving 
forth,  on  pressure,  of  a  parchment-like  crackling  ;  with  this  last  the 

*  Diseases  and  Surgery  of  the  Mouth,  Jaws,  and  Associate  Parts. 
(846) 


TUMORS    OF   THE  MOUTH.  847 

writer  seems,  however,  to  have  had  a  peculiar  experience,  for,  while 
he  has  treated  quite  his  share  of  such  cases,  it  has  not  been  his 
fortune  to  find  such  crackling  sound  in  any  one  of  them,  and 
while  of  course  it  would  ill  become  any  individual  to  assert  that 
such  a  crackling  never  can  be  heard,  yet  it  is  to  be  impressed  that 
such  a  sign  is  not  by  any  means  an  ever-present  indication,  conse- 
quently is  not  to  be  given  the  heed  demanded  for  it.  In  most  of 
these  tumors,  septi,  more  or  less  in  number,  have  been  found  sup- 
porting the  vault;  with  the  presence  of  such  pillars,  it  is  plain 
enough  that  yielding  would  be  out  of  the  question,  so  that  the 
practitioner  is  not  to  be  deceived  by  the  firm  character  of  the  tumor. 
The  gum  covering  such  cystic  tumors  is  always  perfectly  normal, — 
no  congestion,  nothing  indicating  its  implication  ;  a  matter  impor- 
tant to  observe,  as,  should  the  diagnosis  be  in  any  wise  obscure,  the 
practitioner  would  have  at  least  the  satisfaction  of  feeling  a  toler- 
able assurance  as  to  the  benign  character  of  the  growth  as  well  as 
to  its  non-acute  character. 

Of  the  number  of  cysts  of  this  class  treated  by  the  author,  every 
one  has  been  situated  in  the  outer  or  vestibular  walls  of  the  bones. 
Why  they  should  have  been  so,  or  indeed  whether  it  is  always  the 
case,  he  does  not  know.     An  individual  experience  alone  is  offered. 

A  diagnosis  made  out,  the  cure  is  very  simple.  A  common  treat- 
ment, and  one  generally  practiced,  because  of  its  little  trouble,  is  to 
make  a  crucial  incision  through  the  body  of  the  tumor,  and,  break- 
ing up  such  septi  as  may  exist,  stuff  the  cavity  with  lint  saturated 
with  the  tincture  of  iodine:  this,  if  there  be  no  foreign  body  in  the 
cavity,  as,  for  instance,  the  root  of  a  dead  tooth,  will  invariably 
cause  the  base  to  throw  out  granulations,  and  thus  obliterate  the 
cyst. 

Another  mode,  not  unfrequently  resorted  to,  is  to  dissect  from  the 
tumor,  in  flap-form,  the  overlying  gum,  and  with  a  chisel  cut  away 
the  vault  of  the  cyst;  the  parts  are  then  carefully  syringed  and  the 
flap  laid  back.  This  latter  operation  requires  much  more  time,  much 
more  skill,  and  gives  much  more  pain.  The  first  is  not  nearly  so 
objectionable  to  the  patient,  and  is  equally  effectual. 

Concerning  hemorrhage,  little  anxiety  need  be  felt.  It  is  seldom 
found  to  give  any  trouble  ;  it  may  be  necessary  to  syringe  the  cavity 
with  a  little  alum-water,  or  some  other  astringent,  but  even  this  is 
not  commonly  needed. 

Case. — Mrs.  C,  aged  about  twenty-one,  applied  to  the  author, 
some  two  years  ago,  for  treatment  of  a  tumor  occupying  the  canine 


ORAL   DISEASES  AND   SURGERY. 

fossa  of  the  left  superior  maxillary  bone.  The  growth  had  been 
eighteen  months  in  progress  ;  was  about  the  size  of  half  a  walnut, 
perfectly  solid  to  the  touch,  painless,  and  entirely  healthy-looking  ; 
the  greatest  disquietude  of  the  patient  being  mental,  her  mother 
having  died  from  scirrhous  cancer. 

Diagnosis. — Simple  cyst. 

Treatment. — Crucial  incisions  were  made ;  several  delicate  septi 
of  bone,  which  the  cuts  revealed,  were  broken  up ;  the  cyst  was 
injected  for  the  first  three  days  with  weak  stimulating  liquors.  No 
inflammation  developing,  tufts  of  cotton  were  saturated  with  tinc- 
ture of  iodine,  and  the  cyst  stuffed  with  them.  In  one  week  the  site 
of  the  cavity  was  occupied  by  healthy  granulations  ;  in  three  weeks 
the  patient  was  entirely  cured,  and  left  the  city  for  her  home  in  an 
adjoining  State. 

Case. — About  nine  months  back,  a  German  woman  applied  with 
a  cystic  tumor,  similar  to  the  above ;  it  Avas  certainly  as  unyielding 
as  solid  bone.  This  tumor  was  treated  by  making  a  crucial  incision 
through  the  soft  parts  alone ;  the  flaps  were  then  dissected  off,  and 
the  cyst,  being  exposed,  was  cut  away  with  a  chisel-shaped  instru- 
ment. The  flaps  fell  naturally  into  the  cavity,  and  were  left,  even 
without  a  stitch,  to  take  care  of  themselves.  The  cure  was  com- 
plete in  about  a  week. 

The  above  constituted  the  description  and  the  illustrations  offered 
of  the  simple  cysts;  but  in  the  mind  of  the  writer  there  existed  a 
degree  of  confusion,  because  in  some  of  these  cysts  nothing  was 
found,  and  a  tumor  strictly  local,  as  these  always  prove  to  be, 
should  not  be  without  local  explanation.  This  explanation  the 
author  has  now  found  in  an  enlarged  experience,  in  which,  in  every 
individual  instance  over  which  he  has  extended  his  inquiries,  he 
has  been  able  to  demonstrate  entirely  an  origin  of  the  cysts  in 
dental  disease.  Close  observation  in  most  of  them  will  discover 
some  mere  particles,  it  may  be,  of  an  unabsorbed  tooth-root,  a  re- 
trograding metamorphosis,  fully  explaining  an  empty  condition  of 
this  cyst,  which  later  would  necessarily  have  been  met  with.* 


*  There  is  a  tuilior  of  the  soft  parts  of  the  jaw — cystic,  but  not  osseous — 
which  must  not  be  confounded  with  the  class  just  described.  Both  look,  occa- 
sionally, precisely  alike,  but  the  latter  yields  under  pressure,  as  any  semi-soft 
tumor  would  yield.  Mr.  Paget  alludes  to  such  a  disease  in  his  lectures  on 
Surgical  Pathology,  pages  342-3.  "A  woman,"  he  says,  "  thirty-eight  years 
old,  was  under  my  care  in  1849,  in  whom,  at  first  sight,  I  could  not  but  suppose 


{ 


TUMORS   OF   THE  MOUTH.  849 

The  odontocele  proper  is  exhibited  in  Fig,  265. 

In  the  diagram  a  large  tumor  is  recognized  to  have  existed  in  the 
body  of  the  lower  jaw,  cystic  in  character,  as  seen  by  the  section  c, 
the  exciting  lesion  of  which,  b,  a  tooth-crown,  is  seen  lying  in  the 
cavity. 

The  diagnosis  of  an  odontocele  may  seldom  be  a  matter  of  doubt. 
The  form  here  presented  is  the  subject  in  its  simplest  expression ; 
from  this  it  varies  to  the  complex  dentigerous  tumor,  an  example  of 
which  is  presented  on  the  succeeding  pages. 

An  odontocele  may  present  itself  in  any  part  of  the  ossa  maxillae, 
and,  what  is  of  much  consequence  to  be  remembered,  may  have,  as 
the  lesion  of  departure,  a  supernumerary  tooth. 

The  absence  of  a  tooth  or  teeth  from  the  arch  through  nou-devel- 


sometbing  was  distending  the  antrum,  so  closely  was  deformity  of  the  face 
due  to  such  disease  imitated.  But  the  swelling  was  soft  and  elastic,  and  pro- 
jected the  thin  mucous  membrane  of  the  gum  of  the  upper  jaw,  like  a  half- 
empty  sac.  I  cut  into  this  sac,  and  let  out  nearly  an  ounce  of  turbid,  brownish 
liquid,  sparkling  with  crystals  of  cholesterine.  The  posterior  wall  of  the  cyst 
rested  in  a  deep  excavation  on  the  surface  of  the  alveolar  border  of  the  upper 
jaw;  an  adaptation  of  shape  attained,  I  suppose,  as  the  result  of  the  long- 
continued  pressure  of  the  cyst,  which  had  existed  six  years." 

The  same  author  also  makes  mention  of  a  young  man  under  his  care  with 
a  similar  tumor,  which,  he  says,  was  the  result  of  an  injury  to  the  gum  or 
alveolar  border  six  months  previously.  In  neither  of  these  cases,  he  remarks, 
could  he  find  any  disease  of  the  maxillary  bone.  The  origin  of  such  cysts, 
so  far  as  the  experience  of  the  writer  goes,  is  to  be  found  in  a  diseased  tooth- 
fang.  There  surely  would  have  been  found  to  be  at  best  one  little  shot-like 
hole  somewhere  about  the  surrounding  osseous  wall ;  at  any  rate,  such  is  the 
history  as  I  have  met  with  them. 

A  succeeding  case,  which  Mr.  Paget  mentions,  seems  to  prove  the  tumors 
to  be  the  same  as  I  refer  to.  "  A  lady,"  he  says,  "  had  a  small  cyst  of  this 
kind,  which  had  existed  twenty-seven  years,  filling  and  discharging  almost 
daily.  It  had  its  origin  in  a  blow,  by  which  the  two  median  incisors  were 
loosened."* 

A  few  winters  back,  a  physician  from  Kentucky  applied  to  the  author  for 
treatment  of  a  tumor  of  the  lower  jaw,  which  had  existed  for  over  two  j^ears  : 
it  had  the  feel  of  a  fibroid  body.  This  gentleman,  with  the  imaginative 
qualities  common  to  the  practitioner  when  he  himself  becomes  a  patient,  had 
succeeded  in  satisfying  himself  of  the  cancerous  character  of  his  trouble.  An 
incision  through  the  growth  demonstrated  it  to  be  a  cold  alveolar  abscess.  In 
a  single  week  he  was  cured  ;  the  treatment  required  was,  simply  .keeping 
the  incision  patulous,  and  using  a  few  stimulating  injections. 


*  This  historj'  is  that  of  chronic  alveolar  abscess  in  every  particular. 

53 


850 


ORAL  DISEASES  AND  SURGERY. 


opment,  coojoined  with  the  presence  of  a  non-vascular  tumor,  affords 
inference  of  the  existence  of  odoutocele. 

Fig.  265. 


In  the  case  of  supernumerary  teeth,  or  of  doubt  as  to  absence  of 
teeth  through  non-development,  the  use  of  the  exploring-needle, 
striking  the  glossy,  slippery  enamel,  will  always  explain  the  ordinary 
condition. 

Illustrations. — A  young  lady,  aged  sixteen,  presented  herself, 
having  a  tumor,  intramaxillar}^  evidently,  occupying  the  anterior 
left  side  of  the  hard  palate.  Her  exact  condition  was  as  follows. 
She  had  never  had  a  single  tooth  of  the  permanent  set  extracted, 
yet  she  lacked,  to  make  up  the  complement  common  to  her  age,  the 
canine  of  the  affected  side.  The  tumor  was,  of  course,  an  odouto- 
cele, or  at  least  so  great  was  the  probability  of  such  being  its  char- 
acter, considering  the  absence  of  the  tooth  from  the  dental  arch,  that 
any  surgeon  would  feel  justified  in  founding  a  proposed  operation 
on  such  conviction.     The  exploring-needle  verified  the  conclusion.* 

In  1861  the  following  very  interesting  case  of  odontocele  came 
under  the  observation  of  the  author.  The  patient,  desiring  a  set  of 
artificial  teeth,  about  a  year  previous,  had   had  all  the  teeth  of  the 


*  Eefer,  for  proper  appreciation  of  the  subject  of  encysted  teeth,  to  page 
145,  and  for  diagrams  to  pages  158,  160,  161,  163,  167. 


TUMORS   OF  THE  MOUTH.  851 

upper  jaw  extracted,  and,  as  is  customary  (not  desiring  to  wear  a 
temporary  denture),  had  been  dismissed  for  a  period  of  some  four 
months.  At  the  end  of  this  time  the  impression  of  his  mouth  had 
been  taken,  the  parts  being  in  a  good  healthy  condition.  The  teeth 
were  made,  placed  in  position,  and  worn  with  entire  comfort  for  a 
period  of  several  months. 

About  eight  weeks  before  presenting  himself,  these  artificial  teeth 
were  found  to  be  getting  loose,  as  if  from  some  projection  at  the 
right  border  of  the  myrtiform  fossa.  Applying  to  his  dentist,  sur- 
prise was  expressed  at  the  occurrence,  and  advice  given  that  the 
further  progress  of  the  case  should  be  awaited.  At  this  period  the 
gums  were  more  or  less  congested,  and  were  putting  on  quite  an 
angry  appearance;  a  few  days  later  a  fistula  formed.  His  dentist, 
confident  that  no  portion  of  the  roots  of  any  of  the  teeth  had  been 
left  in  the  alveolus,  now  dismissed  the  case,  advising  him  to  seek 
surgical  assistance.     In  this  condition  he  came  under  observation. 

The  case  now  presented  the  following  features  :  much  engorge- 
ment of  all  that  portion  of  the  gum  and  lip  covering  the  incisive 
and  canine  fossie,  which  engorgement  extended  in  a  triangular 
direction  to  the  inner  canthus  of  the  right  eye,  much  soreness  on 
pressure  o\^er  all  the  affected  parts,  the  fistula  discharging  thin  and 
occasionally  bloody  pus. 

Examination  with  the  probe  gave  the  impression  that  it  struck 
against  the  root  of  a  tooth,  which  would  certainly  have  influenced 
the  making  up  of  the  diagnosis  if  experience  had  not  suggested 
that  no  tooth  could,  under  ordinary  circumstances,  have  a  fang  ex- 
tending such  a  length. 

Deducing  from  the  conditions  present  the  imperative  necessity  for 
an  exploration,  and  the  patient  willingly  acceding  to  the  conclusion, 
the  following  course  was  pursued.  The  patient  was  etherized.  An 
assistant,  having  sponge  and  water  at  his  side,  took  charge  of  the 
lower  jaw  and  lip.  A  second  assistant  steadied  the  head  and  held 
the  superior  lip  well  out  of  the  way  of  the  knife. 

The  parts  being  thus  very  fairly  exposed,  a  pointed  and  some- 
what delicate-bladed  bistoury  was  passed  from  the  superior  fleshy 
boundary  of  the  canine  fossa  to  the  inner  canthus.  The  cut  passed 
not  only  through  the  soft  parts,  but,  in  the  return,  sunk  readily  into 
the  bone.  A  first  flap  was  now  dissected  posteriorly  from  the  dead 
mass :  a  second  was  bounded  mesially  by  the  nasal  bone,  ala,  and 
left  prominence  of  the  myrtiform  fossa.  The  blood  being  sponged 
away,  there  was  discovered,  lying  in  the  very  centre  of  the  carious 


852  ORAL  DISEASES  AND   SURGEBY. 

bone,  a  cuspid  tooth  of  ordinary  size   and  development,  the   apex 
being  in  immediate  relation  with  the  floor  of  the  orbit. 

That  this  tumor  had  existed  for  a  long  time  is,  of  course,  not  to  be 
doubted,  but  it  excited  the  attention  of  the  patient  only  on  the  setting 
up  of  acute  inflammatory  action.  This  inflammation  soon  destroyed 
the  integrity  of  the  vault  of  the  cyst :  hence  the  softened  carious 
state  in  which  it  was  found.  The  interest  associated  with  the  case 
lies  in  the  absence  of  all  the  teeth  by  extraction,  and  the  consequent 
loss  of  data  for  the  diagnosis.*  A  tumor  precisely  similar  is  de- 
scribed by  Dupuytren. 

*  "  In  1862, 1  published,  in  the  Boston  Medical  and  SurgicalJournal,  a  case 
occurring  in  an  elderly  woman  of  a  cyst  which  involved  the  ascending  por- 
tion and  condyles  of  the  jaw,  and  which  I  removed ;  not  thinking  it  safe,  in 
a  person  of  her  age,  when  the  disorganization  of  the  jaw  seemed  to  be  so 
complete,  to  run  the  risk  of  an  experimental  mode  of  treatment.  Since  that 
time,  I  have  had  an  opportunity  of  trying  the  conservative  plan  of  treatment 
in  two  instances,  which  I  propose  shortly  to  relate. 

"  Notwithstanding  the  principle  which  has  been  suggested  or  hinted  at  for 
the  treatment  of  large  cystic  tumors  of  the  jaw,  none  of  the  writers  on  the 
subject  have  presented  cases — where  complete  destruction  of  the  bone  has 
taken  place,  leaving  nothing  but  a  delicate  cyst — which  have  been  successfully 
treated  by  the  method  referred  to.  Dupuytren,  in  his  work  on  'Diseases  of 
the  Bones,'  gives  several  cases  treated  without  excision;  some  of  them,  how- 
ever, unsuccessfully.  M.  Nelaton  has  also  written  upon  the  subject,  referring 
for  cases  to  the  work  of  Dupuytren,  and  advising  the  puncture  of  the  cyst 
and  thestuflSngof  its  cavity  with  lint.  Mr.  Erichsen  says,  'when  the  cysts  are 
so  large  that  they  have  destroyed  the  integrity  of  the  bone,  or  when  they  are 
associated  with  a  large  quantity  of  fibrous  tissue,  so  as  to  constitute  true  fibro- 
cystic tumors,  excision  of  the  diseased  bone  must  be  practiced.'  Mr.  Stanley, 
in  his  '  Treatise  on  the  Diseases  of  the  Bones,'  describes  perfectly  the  affection, 
but  does  not  allude  to  any  other  operation  than  the  '  removal  of  the  tumor 
and  of  the  portion  of  the  bone  from  which  it  has  arisen,' 

"  In  the  two  following  cases  the  treatment  consisted  in  the  puncture  of  the 
sac  within  the  mouth,  evacuating  its  contents,  and  at  the  same  time  obliter- 
ating its  cavity  by  crushing  in  its  walls ;  and  lastly,  in  keeping  up,  by  injec- 
tions, etc.,  a  sufficient  degree  of  irritation  to  favor  the  deposition  of  new  bone. 
The  comparative  mildness  of  this  mode  of  treatment,  and  the  excellent  char- 
acter of  the  results,  combine  to  award  the  preference  for  this  operation  over 
excision,  or  even  the  large' external  incision  adopted  by  Dupuytren. 

"  Cystic  Tumor  of  the  Lower  Jaw.  Case  I. — A  young  woman,  aged  twenty- 
five,  with  light  hair,  blue  eyes,  and  delicate  skin,  applied  to  me,  in  the  spring 
of  1862,  on  account  of  a  large  tumor  involving  the  whole  right  side  of  the  jaw 
above  its  angle.  The  tumor  was  of  a  globular  shape,  extended  back  under 
the  lobe  of  the  ear,  forward  so  as  to  encroach  upon  the  cavity  of  the  mouth, 
and  upward  so  as  to  press  upon  and  somewhat  to  overlap  the  zygoma.     The 


I 

i 


TUMORS   OF   THE  MOUTH.  853 

Osteo-dental  tumors  dependent  on  the  development  of  supernu- 
merary teeth  are  quite  common ;  they  are  generally  easily  recognized 

external  surface  of  the  tumor  was  smooth  and  shining,  slightly  (Edematous, 
and  she  suffered  somewhat  from  its  pressure  upon  the  surrounding  organs.  It 
had  commenced,  some  years  before,  by  a  swelling  at  the  root  of  the  wisdom- 
tooth  of  the  right  side,  and  the  inconvenience  caused  by  its  pressure  had 
become  so  great  as  to  lead  her  to  take  measures  for  its  removal. 

"Upon  consultation,  it  was  decided  that  a  portion  of  the  jaw  would  proba- 
bly require  removal,  the  tumor  having  been  first  exposed  hy  an  incision  made 
inside  of  the  mouth,  to  verify  its  character. 

"The  following  operation  was  performed  under  the  influence  of  ether:  An 
incision  was  made  in  the  most  prominent  part  of  the  tumor  in  the  mouth, 
upon  which  a  large  quantity  of  glairj^  fluid  escaped.  Upon  passing  the  flnger 
into  the  opening,  it  was  found  that  the  whole  jaw,  at  this  point,  with  the 
articulating  and  coronoid  processes,  was  expanded  into  a  mere  .shell,  at  some 
parts  as  thin  as  parchment,  and  destitute  of  osseous  substance.  It  was  with- 
out solid  contents.  Under  these  circumstances,  and  considering  the  good 
health  and  youth  of  the  patient,  it  was  determined  to  make  the  attempt  to 
save  the  jaw.  A  portion  was  therefore  removed  from  the  sac,  and  with  the 
fingers  the  sides  of  the  cavity  were  made  to  collapse,  so  as  to  come  in  contact 
with  each  other.  In  order  to  excite  still  further  irritation,  a  bit  of  cotton 
cloth  was  forced  into  the  interior,  and  the  end  left  projecting  into  the  mouth. 
A  moderate  degree  of  irritation  followed,  and  in  a  day  or  two  the  pledget  was 
removed,  suppuration  having  commenced  in  the  sac.  The  aperture  was 
dilated  from  time  to  time  by  the  introduction  either  of  the  finger  or  of  a 
bougie,  and  the  sac  injected  with  tincture  of  iodine.  In  two  or  three  weeks 
she  left  the  hospital,  with  the  tumor  reduced  to  about  half  its  original  size. 
From  that  time  until  the  present,  she  has  occasionally  visited  me  at  my  house, 
and  by  keeping  the  external  opening  free,  and  occasionally  irritating  the 
interior  of  the  sac,  a  solid  mass  of  bone  has  been  deposited  anew,  and  the 
jaw  has  resumed  somewhat  of  its  original  shape.  The  sac  is  in  the  way  of 
becoming  entirely  obliterated. 

"  In  ISTovember,  1863, 1  again  saw  the  patient,  who  came  to  consult  me,  not 
about  herself,  but  about  a  friend.  All  signs  of  the  tumor  were  gone,  and  the 
jaw  had  regained  almost  its  natural  shape;  but  a  small  aperture  still  existed 
at  the  site  of  the  former  opening  into  the  mouth,  from  which  a  glairy  fluid 
was  occasionally  discharged.  She  was  quite  well,  and  all  the  functions  of  the 
jaw  were  perfectly  performed. 

"  Subsequently  she  applied  to  me  with  a  similar  tumor,  but  of  a  much 
smaller  size,  which  had  appeared  anterior  to  the  site  of  the  first  one.  It  was 
treated  in  a  similar  manner,  with  similar  result. 

"Case  II.— May  23,  1863,  Dr.  Bennett,  of  Uxbridge,  Mass.,  brought  me 
as  a  patient  a  gentleman  fifty-six  j'ears  of  age,  with  a  large  tumor  on  the 
right  side  of  the  face  and  parotid  region.  He  was  of  a  pale  and  yellowish  color, 
much  emaciated,  and  his  aspect  at  first  struck  me  as  that  of  a  person  sutferiiig 
from  malignant  disease.     He  said  that,  five  years  before,  while  eating,  he 


854  OBAL  DISEASES  AND    SURGERY. 

from  their  position  and  size,  being  seldom  larger  than  an  ordinary 
pea,  and  mostly  situated  in  some  part  of  the  palatine  processes  of 

'  had  the  sensation  of  something  giving  way  in  the  neighborhood  of  the  ascend- 
ing ramus  of  the  lower  jaw.  Shortly  after,  a  tumor  appeared  in  that  region, 
which  had  slowly  increased  to  its  present  size.  Before  making  an  examina- 
tion, it  was  not  easy  to  say  whether  the  tumor  was  connected  with  the  parotid 
gland  or  with  the  jaw.  From  the  first  commencement  of  the  tumor  to  the 
present  time,  mastication  and,  for  a  good  part  of  the  time,  deglutition  had 
been  much  interfered  with.  The  tumor  had  been  examined  by  many  physi- 
cians of  experience,  and  by  most  of  them  considered  as  a  parotid  tumor,  and, 
as  the  patient  inferred,  although  he  was  not  directly  told  so,  of  a  malignant 
character.  It  extended  backward  into  the  parotid  region,  upward  upon  the 
face,  and  inward  so  as  to  occupy  the  right  half  of  the  palate,  and  was  covered 
with  a  highly  irritable  mucous  membrane,  somewhat  oedematous,  and  similar 
to  what  we  often  see  investing  malignant  tumors  in  the  mouth  which  have 
made  their  way  through  from  the  neck.  During  an  examination,  the  patient 
said  there  had  been  of  late  a  slight  discharge  of  fluid  into  the  mouth,  and  on 
making  a  careful  inspection  a  minute  aperture  was  detected  at  the  point 
where  the  last  molar  tooth  had  been  removed. 

"  On  introducing  a  probe  at  this  point,  a  jet  of  serum,  mixed  with  flakes  of 
lymph,  was  projected  to  a  considerable  distance.  I  immediately  enlarged  the 
opening  with  a  knife,  so  that  I  could  introduce  the  finger.  This  was  a  matter 
of  some  difficulty,  howcvei",  as  the  patient's  jaws  had  been  for  a  long  time 
nearly  closed  in  consequence  of  the  disease.  The  finger  penetrated  into  a 
large  sac  extending  far  out  of  reach,  and,  on  investigation,  it  soon  became 
evident  that  the  whole  tumor  was  formed  by  the  expansion  of  the  jaw  from 
the  development  within  it  of  an  immense  cyst.  On  withdrawing  the  finger, 
a  barrier  of  bone  was  felt  extending  across  the  jaw,  and  behind  it,  under  the 
first  molar  tooth,  another  smaller  sac  was  discovered. 

"  I  now  decided  to  treat  this  case  in  a  similar  manner  to  the  preceding  one. 
An  oblong  piece  of  about  an  inch  in  length  and  half  an  inch  in  width  was 
removed  by  scissors  from  the  wall  of  the  cyst,  and,  with  a  finger  of  one  hand 
in  the  mouth,  and  a  finger  of  the  other  on  the  outside  of  the  face,  the  sides 
of  the  cyst  were  broken  down,  giving  way  under  pressure  like  parchment, 
with  a  crepitating  noise.  The  projection  of  the  tumor  on  the  face,  as  well  as 
within  the  mouth,  became  in  a  great  measure  eflaced.  There  was  a  slight 
but  unimportant  oft'usion  of  blood.  The  patient  returned  home  under  the 
charge  of  his  physician,  with  the  intention  of  pursuing  pretty  much  the  same 
course  as  was  adopted  in  the  former  instance.  On  account  of  his  age,  and 
the  debility  caused  by  the  want  of  proper  nourishment,  and  owing  to  the 
difficulty  of  mastication,  he  was  ordered  tonics  and  a  nutritious  diet. 

"About  four  weeks  later  I  saw  him  again.  Everything  had  gone  on  well. 
The  tumor  was  not  more  than  a  fourth  as  large  as  formerly,  and  bone  had 
begun  to  be  deposited  in  the  walls  of  the  sac.  His  health  was  wonderfully 
improved,  and  his  complexion  had  assumed  a  healthy  hue. 

"December  8,1863. — I   saw  him  for  the  third  time,   so  altered  for  the 


1 


TUMORS   OF  THE  MOUTH.  855 

the  superior  maxillae.  Any  obscurity,  however,  in  these  tumors  is 
readily  dispersed  by  thrusting-  into  them  a  bistoury,  or,  as  suggested, 

better  as  scarcely  to  be  recognized  as  the  same  person.  The  jaw  externallj' 
had  resumed  its  natural  shape,  and,  on  examination  with  the  finger,  its  dis- 
tincti-^e  anatomical  marks  and  processes  could  be  felt.  On  the  inside,  where 
the  incision  had  been  made,  a  deep  sulcus  was  observed,  lined  with  mucous 
membrane,  into  which  a  probe  could  be  passed  into  the  ascending  ramus. 
There  was  no  discharge  to  be  detected,  and  the  power  of  mastication  was  as 
good  as  ever.  The  only  trouble  he  experienced  was  from  the  lodgment  of 
food  in  its  cavity. 

"Three  months  later,  he  was  seen  with  the  jaw  in  a  perfectly  healthy  con- 
dition, having  all  its  functions,  and  the  only  change  fi:om  the  normal  state  was 
perhaps  a  somewhat  more  solid  and  thickened  condition  than  natural,  with  a 
sulcus  existing  at  the  back  part  where  the  tumor  had  originated. 

"  In  1866  he  made  me  a  visit  for  the  purpose  of  showing  the  complete  suc- 
cess of  the  operation. 

"  Cystic  Tumor  of  the  Upper  Jaw.  Case  III.— A  young  lad}^,  aged  sixteen, 
of  English  parentage,  was  brought  to  me  in  May,  1865,  on  account  of  a  'tumor 
which  had  been  developing  for  the  last  three  years,  in  the  alveolus  of  the 
right  upper  jaw,  just  above  the  canine  and  bicuspid  teeth.  Three  years  befoTe 
the  nerve  of  the  canine  tooth  had  been  destroyed  by  arsenic,  and  the  carious 
cavity  filled  with  gold,  the  first  bicuspid  also  being  filled  at  the  same  time. 
Irritation  soon  commenced  at  the  roots  of  these  teeth,  and  gradually,  almost 
imperceptibly,  a  swelling  appeared  there.  A  month  before  she  came  to  me, 
this  tumor  opened  at  its  most  dependent  part,  discharging  a  glairy  fluid,  which 
continued  to  exude  until  I  saw  the  case. 

"  The  aperture  admitted  a  small  probe,  which  penetrated  into  a  deep,  smooth 
cavity.  With  the  finger,  the  tumor  from  below  appeared  firm ;  but,  when 
pressed  upon  under  the  gum,  a  degree  of  elasticity  was  distinguished. 

"  I  informed  the  parents  of  the  young  lady  that  the  disease  was  a  cystic 
tumor  of  the  bone,  and  advised  an  operation.  This  was  assented  to.  The 
patient  was  etherized,  and  a  cut  made  into  the  tumor.  The  mucous  membrane 
was  then  dissected  up  from  its  surface,  so  as  to  expose  so  much  of  the  bony 
sac  as  would  admit  of  a  free  opening  being  made  into  it,  and  the  portion  of 
bone  was  removed  with  scissors.  The  finger  could  now  be  passed  freely  into 
the  cavity,  which  was  quite  smooth  and  entirely  lined  with  membrane;  it 
was  not  penetrated  by  the  roots  of  any  of  the  adjacent  teeth.  The  cavity  was 
stutfed  with  lint,  in  order  to  excite  inflammatory  action,  for  the  purpose  of 
obliterating  the  sac. 

"  The  operation  had  all  the  etTect  that  could  have  been  desired.  In  the 
course  of  a  couple  of  months,  granulations  filled  up  the  cavity,  entirely  oblit- 
erating it.     She  was  completely  relieved  of  the  disease. 

"  One  or  two  other  cases  of  cysts  in  the  upper  jaw  I  have  treated  in  the  same 
way,  with  a  similar  result." — J.  Mason  Warren,  M.M., /rom  a  paper  read 
before  the  Massachusetts  Medical  Society. 


856 


ORAL  DISEASES  AND   SURGERY. 


the  exploring-needle.  The  dental  surgeon  particularly  would  remark 
from  the  sense  of  touch  whether  or  not  the  contents  are  tooth-sub- 
stance. 

Fig.  266  is  a  cut  furnished  the  author  by  Dr.  Goodwillie,  representing  a 
dentigerous  tumor,  treated  by  section.    Examination  revealed  the  following  : 

Fig.  266. — Dentigerous  Tumor. 


On  the  top  of  the  tumor,  as  is  seen,  was  a  portion  of  the  enamel  of  the 
crown  of  a  tooth,  very  much  like  a  half-decayed  deciduous  molar.  The  part 
below  this,  in  external  appearance,  was  rough  on  the  surface,  and  seemed 
dense  in  structure,  with  the  exception  of  a  concave  surface  on  the  bottom  of 
the  tumor,  which  was  quite  porous,  and  sticking  out  from  this  were  a  number 
of  spines,  between  which  were  minute  openings  into  the  centre  of  the  tumor  for 
the  passage  of  the  vessels  of  the  pulp. 

Alongside  of  this  were  two  other  concave  surfaces,  not  so  deep,  but  dense  and 
somewhat  smooth.  These  were  produced  by  the  cusps  of  a  molar  tooth  found 
below  the  tumor  at  this  point,  but  very  much  destroyed  by  the  pus  in  which 
they  were  found.  These  were  probably  the  cusps  of  the  first  permanent  molar, 
and  the  tumor  was  the  last  deciduous  molar  presenting  this  abnormal  appear- 
ance.    No  other  teeth  were  found. 

On  making  a  section  of  the  tumor,  there  were  seen  columns  or  spiculiE  run- 
ning from  the  circumference  to  the  centre,  forming  quite  a  net-work,  in  which 
the  pulp  was  held,  so  that,  instead  of  there  being  one  pulp  chamber,  there 
were  manj'. 


TUMORS   OF   THE  MOUTH. 


857 


Osteo-dental  tumors  not  unfrequeatly  have  as  their  contents  un- 
developed teeth.  Only  a  few  days  ago  the  author  saw  a  couple  of 
bicuspid  crowns,  evidently  long  dead,  which  had  been  removed  from 
one  of  these  oral  compound  cysts. 

Such  osteo-dental  tumors,  then,  as  just  illustrated,  may  be  viewed 
as  the  most  simple  of  these  compound  cysts.  Another  class,  the  com- 
plex osteo-dental  cyst,  may  now  claim  attention.  No  better  illustra- 
tion of  this  class  of  tumor  can  be  found  on  record,  perhaps,  than  in 
the  memoir  of  the  Guadeloupe  banker's  son,  by  M.  Forget,  presented 
to  the  French  Academy,  and  so  ably  and  happily  republished  in 


Fig.  267,  drawn  from  a  section  of  this  tumor,  made  by  Dr.  Arnold,  repre- 
sents the  dental  tissues  in  a  deranged  and  distorted  condition.  The  internal 
structure  was  very  much  fenestrated. 


a,  a,  represents  the  enamel  at  the  top  of  the  tumor  penetrating  into  fissures 
or  depressions  in  the  mass  below. 

b,  b.  Here  is  represented  the  dentine,  passing  from  the  centre  in  two  direc- 
tions,— in  one  instance  passing  between  two  layers  of  enamel,  and  in  the 
other  between  enamel  and  cement. 

c,  The  cement  is  here  to  be  seen  recognized  by  the  presence  of  lacunae. 
/,/,/,  represent  the  fenestrae,  once  occupied  by  the  dental  pulp.     Around 

some  of  these  may  be  seen  the  distorted  dental  tubuli. 


858  ORAL  DISEASES  AND   SURGEBY. 

English  some  years  since  by  the  publishers  of  the  Dental  Cosmos. 
As  the  illustrations  and  text  are  still  in  possession  of  that  journal, 
the  reader  interested  in  the  subject  cannot  do  better  than  give  them 
most  attentive  consideration,  while  certainly  the  author  cannot  do 
better  than  use  them.  I  preface  by  remarking  that  by  a  complex 
osteo-dental  tumor  is  meant  a  cyst  containing  some  complex  mass, 
which  common  observation,  or  the  microscope,  reveals  as  being 
made  up  of  irregular  developments  of  dental  tissues.* 

*  Observation. — 1.  Osteo-Dental  Tumor,  size  of  a  large  Egg,  encysted  in 
the  thick  part  of  the  Inferior  Maxillary/ —  Ulcerous  Injiammaiion  of  the  Parietes 
of  the  Cyst — Numerous  Ossifluent  Fistulie — Resection  of  the  left  half  of  the 
Body  of  the  Jaw  and  a  portion  of  its  Branch — Cured. 

Early  in  May  a  banker,  of  Guadeloupe,  introduced  to  M.  Forget  his  son, 
whom  he  had  brought  to  Paris  with  the  intention  of  subjecting  him  to  the 
necessary  surgical  operation  for  the  remedj'  of  a  disease  of  the  inferior  maxilla, 
which  had  made  its  first  appearance  when  the  patient  was  five  years  old. 

History  of  the  Disease. — At  that  period  (five  years),  young  L.  sufl^ered 
from  pains  in  his  left  jaw;  they  were  for  some  time  intermittent,  then  con- 
tinuous and  acute.  When  the  patient  was  seven  years  of  age,  two  small 
healthy  molars  were  extracted,  under  the  impression  that  they  were  prevent- 
ing the  evolution  of  the  second  teeth.  The  operation  gave  great  relief,  and 
the  pain  ceased  ;  but  shortly  afterward  a  small,  round,  hard  tumor  appeared 
on  the  external  face  of  the  jaw,  near  the  alveoli  of  the  teeth  that  had  been 
removed.  The  tumor  caused  no  suifering  to  the  patient,  and  made  no  sensible 
pj-ogress  for  a  period  of  eight  years.  The  whole  of  the  left  side  of  the  jaw 
then  became  tumefied,  and  the  bone,  in  the  language  of  the  patient,  broadened 
and  rounded.  He  also  observed,  at  this  time,  that  the  large  molars,  which 
were  regularly  developed  on  the  right  side,  were  wanting  in  the  diseased 
part. 

This  morbid  enlargement  was  accompanied  by  frequent  fluxions  of  the 
gums,  cheek,  and  whole  left  side  of  the  face.  The  recurrence  of  this  fluxion 
was  attended  with  great  pain,  and  caused  an  increased  tumefaction  in  the  soft 
parts  to  such  an  extent  that  the  diff'erence  between  the  sides  of  the  face  became 
absolute  deformity. 

In  November,  1854,  a  violent  inflammation  occurred  in  the  base  of  the  jaw 
and  the  cervico-maxillary  region.  Antiphlogistic  treatment  was  employed, 
two  applications  of  leeches  were  made,  and  the  inflammatory  symptoms  de- 
creased, and,  fifteen  days  afterward,  purulent  matter  formed  in  the  thick  part 
of  the  cheek,  which  opened  spontaneously,  allowing  the  issue  of  a  large  quan- 
tity of  fetid  pus.  The  opening  of  the  abscess  became  fistulous,  the  surrounding 
tissue  then  detached,  and,  under  them,  the  bone  was  naked  for  a  very  con- 
siderable extent. 

Present  Condition. — -Young  L.,  aged  twenty,  is  strong,  well  developed, 
with  an  excellent  constitution,  and  health  perfect  in  all  respects,  excepting 
the  local  aflTection. 

The  disease  appears  externally  in  a  considerable  tumefaction  of  the  left 


TUMORS   OF   THE  MOUTH. 


859 


With  the  cases  presented  in  the  text  and  foot-notes  we  have  studied 
the  extremes:  a  simple  cyst,  with  a  tooth  in  it,  and  a  tumor  so  com- 


FiG.  268. 


cheek,  which  is  more  than  three  times  its  natural  size,  and  the  tumor  has 
caused  a  very  marked  eccentric  development  of  the  corresponding-  maxillary 
bone. 

"When  the  patient  opens  his  mouth,  which  he  does  without  effort,  the  whole 
left  side  of  the  bone  is  seen  to  resemble  a  large  turkey-egg, — the  base  of  the 
jaw  being  confounded,  without  appreciable  line  of  demarkation,  with  the 
internal  and  external  faces,  which  describe  a  very  considerable  curve. 

The  tumor  is  uniform,  without  depressions  or  any  irregular  swellings  upon 
the  surface.  It  does  not  yield  to  pressure,  and  no  part  of  it  gives  that  sound 
of  crepitation  which  is  characteristic  of  attenuation  of  the  osseous  tissues. 
The  external  swelling  hides  the  superior  and  lateral  part  of  the  neck  ;  the 
enlargement  of  the  bone  has  forced  the  tongue  from  its  true  direction,  and 
the  floor  of  the  mouth  has  been  driven  from  the  left  to  the  right. 

The  alveolar  ridge,  singularly  enlarged,  contains  none  of  the  grinding 
teeth,  except  the  first  bicuspid,  which  stands  regularly  in  its  socket.  The 
tissue  of  the  gums  is  dark-red,  and  unusually  thick  and  hard.  In  a  circum- 
scribed spot,  about  the  size  of  a  twenty- 
centime  piece,  the  tissue  is  broken,  and 
exhibits  an  unequal,  wrinkled,  grayish 
surface,  which  gives  a  dry  sound  when 
struck  with  a  metal,  as  if  the  crown  of 
a  tooth  were  hidden  in  the  cavity. 

In  order  to  complete  the  symptomatic 
description,  it  is  added  that  there  are 
many  ossifluent  fistulous  openings  at 
the  base  of  the  tumor,  and  much  hyper- 
trophy and  hardening  of  the  submaxil- 
lary lymphatic  ganglion. 

The  functional  disorders  arising  from 
the  pathological  condition,  at  first  very 
slight,  are  noticed  at  this  stage  as  in- 
creasing every  day :  embarrassment  of 
vocal  utterance,  mastication  painful 
and  incomplete,  deglutition  effected 
with  difficulty,  and  respiration  very 
difficult  every  time  inflammation  is  re- 
newed in  the  tumor  ;  lastly,  the  patient 
suff'ering  from  two  serious  inconven- 
iences,— one,  the  very  marked  deform- 
ity of  the  face  ;  the  other,  the  incessant 
flow  of  fetid  pus,  proceeding  from  the 
complicated  fistulue  of  the  osteo-dental 
caries. 

M.  Forget  here  describes  the  operation,  the  usual  resection. 


One  incident. 


860 


ORAL  DISEASES  AND   SURGERY. 


plex  in  character  and  structure  that  no  one  but  the  microscopist 
might  hope  to  be  able  to  recognize  it.     Yet  these  tumors,  differing 

however,  should  be  remarked  :  in  making  his  anterior  cut  with  the  chain 
saw,  he  alludes  to  coming  in  contact  with  a  tooth' placed  horizontally  in  the 
thick  part  of  the  bone,  precisely  under  the  alveolus  through  which  he  was 
cutting. 

Anatomical  Examination  of  Tumor. — "With  the  surrounding  soft  parts, 
it  is  described  as  being  an  exact  ovoid.  The  soft  parts,  adhering  to  its  ex- 
ternal face,  were  found  marked  with  many  fistular  passages,  ending  at  inflamed 
and  ulcerous  points  of  osseous  tissue.  This  tissue  was  thin,  soft,  and  depress- 
ible,  and  perforated  by  two  orifices  leading  into  the  interior  of  the  cyst, 
from  which  exuded  a  purulent,  viscid,  reddish  liquid.  A  stylet  introduced 
into  one  of  these  passages  was  stopped  by  a  hard  body,  which,  under  percus- 
sion, sounded  like  a  compact  tissue  deprived  of  its  periosteum.  This  ob- 
ject was  reached  by  dissecting  ofl"  the  gums,  which,  condensed  into  a  thick 
bed,  formed  a  sort  of  operculum  for  the  upper  part,  completing  the  cyst  in 
which  the  morbid  product  was  situated.  The  dissection  exhibited  that  the  jaw 
from  the  ramus  to  the  premolar  had  been  changed  into  a  cavity  containing 
a  compact,  saxiform,  ovoid  mass,  the  size  of  a  large  egg,  grayish,  unequal 
surface,  studded  with  small  tubercles,  surrounded  by  a  bed  of  enamel,  and 
completely  buried  in  the  thick  part  of  the  bone.   (See  Fig.  268.) 


Next,  the  tumor  was  divided  along  its  axis  into  two  unequal  parts,  each 
confined  to  the  corresponding  half  of  the  osseous  cyst  that  was  comprised  in 
the  division.  This  revealed  the  composition  of  the  tumor  :  it  was  formed  of 
a  smooth,  glossy,  compact,  homogeneous,  ivory-like  tissue,  of  a  whitish-brown 
color.  In  the  centre  of  it  a  kind  of  regular  disposition  of  its  elements  is 
described  as  existing,  discernible  by  the  naked  eye.     (See  Figs.  269  and  270.) 


TUMORS  OF   THE  MOUTH. 


861 


so  widely  in  their  features,  are  alike  in  the  most  important  one  of 
being  benign.  Their  prophylaxis  is  the  same,  and  for  a  good  dis- 
tance their  surgery  runs  side  by  side. 

Between  the  tumor  and  the  wall  of  the  cyst  was  a  thick,  fibro-cellular  tis- 
sue, free  on  the  side  of  the  former,  where  it  covered  the  whole  intramaxillary 
portion,  and  was  joined  to  the  latter  by  filamental  prolongations  of  a  cellulo- 
vascular  appearance, —  these  being  attached  to  the  numerous  openings  that 
covered  the  face  of  the  cyst.  The  external  surface  of  this  membrane  was 
bathed  with  a  muco-purulent  liquid,  smelling  like  dental  caries. 

Fig.  270. 


At  the  base  and  anterior  extremity  of  the  tumor,  an  indentation  is  described 
fitting  the  crown  of  a  large  molar  that  stood  between  it  and  the  maxillary 
bone.  (See  Fig.  270,  b.)  A  portion  of  the  same  tooth  caused  a  slight  eleva- 
tion on  the  external  face  of  the  jaw.  (Fig.  269,  c.)  M.  Forget  also  describes 
the  tooth  encountered  in  the  operation.  (Fig.  269,  d.)  Its  location,  as  will  be 
seen,  is  directly  beneath  the  alveolus  of  the  first  molar,  which  is  standing  in 
its  true  position.     (Fig.  269,  e.) 

All  the  teeth,  with  the  exception  of  the  last  two  molars,  it  will  thus  be  seen, 
were  found,  and  the  space  appropriated  for  them  was  filled  by  the  tumor. 
What,  then,  queried  M.  Forget,  could  have  become  of  these  two  great  molars  ? 
It  could  not  be,  he  argued,  that  the  bulbs,  compressed  from  their  very  origin, 
had  disappeared  without  leaving  a  single  vestige  of  their  existence.  The 
numerous  instances,  he  held,  that  had  occurred  of  the  simultaneous  develop- 
ment of  teeth  and  anomalous  productions  in  the  very  centre  of  the  maxillary 
would  not  allow  him  to  think  of  accepting  such  an  explanation.  In  all  the 
analogous  cases  that  had  fallen  under  his  observation,  the  teeth  were  of  the 


§62 


OEAL  DISEASES  AND   SURGERY. 


Dental  tumors,  intennediate  to  these  two  classes,  are  of  various 
features.     But,  with  an  ability  to  recognize  the  dental  elements, — 

ordinary  dimensions,  and  complete  in  number,  although  removed  from  their 
normal  position,  and  sometimes  buried  even  in  the  morbid  substance  itself. 

Let  us  now,  that  we  may  fully  comprehend  such  a  class  of  cases,  pursue 
the  study  of  this  particular  one. 

Fig.  268  represents  the  left  half  of  the  body  of  the  inferior  maxillarj'  bone, 
hollowed  into  a  large  cavity,  containing  an  ivory-like  bony  tumor. 

d.  Side  view  of  the  alveolar  edge. 

a.  Orifice  of  the  dental  canal  upon  the  surface  of  the  resection  of  the  bone 
in  the  continuity  of  the  ramus. 

b.  Plane  of  the  cut  in  front,  showing  the  second  small  molar  which  was 
found  in  it. 

c.  Crown  of  the  first  molar,  in  regular  position. 

Fig.  271. 


Figs.  269  and  270.  The  two  halves  of  the  anatomic  section,  divided  accord- 
ing to  its  axis  (osseous  cyst,  and  included  tumor). 

Fig.  269. — c.  Crown  of  great  molar,  seen  through  a  notch  in  the  outer  wall 
of  the  cyst. 

d.  Second  small  molar. 

e.  First  small  molar. 


TUMORS  OF   THE  MOUTH.  863 

with  an  uuderstauding  of  the  minute  histology  of  enamel,  dentine, 
cemeutum,  and  pulp-substance,. — what  difference  can  it  make,  having 
€yes  and  a  microscope,  how  these  elements  aggregate? 

a  and  b.  Points  of  the  same  wall,  perforated  by  the  prolongation  of  the 
tumor. 

/.  Summit  of  the  most  elevated  of  these. 

Fig.'270. — a.  Interior  aspect  of  the  tumor. 

b.  Great  molar  inverted. 

e  and  d.  Cellulo-fihrous  membrane,  interposed  between  the  osseous  cyst  and 
tumor. 

Fig.  271.   Microscopical  examination. 

M.  Forget,  in  presenting  this  case  to  the  French  Academy,  remarked  that 
it  was  a  duality  of  anatomical  and  pathological  lesion,  so  rare  that,  after  the 
strictest  research,  he  was  led  to  helieve  it  unexampled  in  the  human  species. 
Thus,  then,  we  have  here,  side  by  side,  each  extreme  ;  and,  understanding  each, 
there  is  not  likely  to  come  anj^thing  between  that  we  may  not  be  able  readily 
to  explain. 

A  dental  germ  assuming  or  compelled  to  an  abnormal  position  may  have 
various  sequelas.  It  may  make  a  mal-eruption  ;  it  may  remain  encysted  ;  it 
may  die  after  partial  development,  or  it  may  hcterogeneously  develop. 

We  have,  then,  but  to  consider  heterogeneous  development,  and  we  have 
mastered  the  pathology  of  the  lesion  and  all  its  various  phases. 

First,  let  us  dissect  a  tooth, — for  the  parts  of  a  tooth  are  the  parts  of  such 
tumors.  A  tooth  is  made  up  of  enamel,  dentine,  cementum,  pulp-substance, 
and  periodoDteum. 

Enamel  op  the  Teeth. — Cortex  strata,  adamantina  dentium  ;  crusta  den- 
tium  adamantina;  substantia  vitrea. 

The  enamel  of  a  tooth  is  that  portion  which  caps  the  crown.  In  structure 
it  is  fibrous  ;  its  fibres  radiating  from  the  centre  to  the  surface. 

In  microscopic  structures,  the  enamel  (Owen)  consists  of  long  and  slender, 
solid,  prismatic,  for  the  most  part  hexagonal,  fibres  of  phosphate,  carbonate, 
and  fluate  of  lime ;  which  are  essentially  the  contents  of  extremely  delicate 
memhranous  tubes. 

Dentine. — Os  dentis,  substantia  ossea  ebur  dentis. .  This  is  the  portion  of 
the  tooth  between  the  cementum  and  enamel  and  between  the  pulp  and  the 
enamel.  It  makes  up  the  great  body  of  the  organ.  Dentine  is  composed  of 
numberless  tubules,  these  being  not  larger  than  the  one-ten-thousandth  of  an 
inch  in  diameter  ;  their  course  is  waving,  each  tubule  having  several  curves 
j-esembling,  according  to  Ketzius,  the  Greek  letter  ■&.  "  Professor  lletzius 
-confirms  the  observation  of  Miiller,  that  the  tubes  contain  an  organic  earthy 
matter  in  granular  masses,  which  disappear  under  the  action  of  dilute  muri- 
atic acid.  The  cells,  and  the  small  tubes  which  radiate  from  them,  also  con- 
tain earthy  matter,  as  in  bone.  They  are  naturally  white  and  opaque,  but, 
after  maceration  in  dilute  muriatic  acid,  become  colorless  and  transpai'ent." 

Chemically,  dentine  diflfers  from  enamel  principally  in  the  absence  of  the 
fluate  of  lime. 


864  ORAL  DISEASES  AND  SURGERY. 

The  author  once  saw  a  tumor  taken  from  a  maxilla,  which 
looked  like  a  mass  of  ivory;  it  was  quite  as  large  as  two  of  the 

Cementum — Crttsta  Petrosa. — The  cementum  of  a  tooth  is  that  portion 
which  invests  the  fangs.  In  character,  it  corresponds  quite  closely  to  the 
osseous  structures.  The  microscope  demonstrates  clearly  the  existence  of 
Haversian  canals,  and  the  so-called  corpuscles  of  Purkinje,  or,  as  Pvobin 
prefers  to  term  them,  osteoplasts. 

"  In  growing  teeth,  with  fangs  not  fully  formed,  the  cement  is  so  thin  that 
the  Purkinjean  cells  are  not  visible ;  it  looks  like  a  fine  membrane,  and  has 
been  described  as  the  periosteum  of  the  fangs,  but  it  increases  in  thickness 
with  the  age  of  the  tooth,  and  is  the  seat  and  origin  of  what  are  called  exos- 
toses of  the  fangs,  which  are  wholly  composed  of  it."  "  It  is  the  presence  of 
this  osseous  substance,"  says  Professor  Owen,  "  which  renders  possible  many 
well-known  experiments  of  which  the  human  teeth  have  been  the  subject ; 
such  as  their  transplantation  and  adhesion  into  the  combs  of  cocks,  and  the 
establishment  of  a  vascular  connection  between  the  tooth  and  the  comb,"  etc. 
Under  every  modification,  the  cement  is  the  most  highly  organized  and  most 
vascular  of  the  dental  tissues,  and  its  chief  use  is  to  form  the  band  of  vital 
union  between  the  denser  constituents  of  the  tooth,  and  the  bone  in  which  the 
tooth  is  implanted. 

Dental  Pulp. — The  pulp  is  that  vascular,  reddish-gray,  highly-sensitive 
substance  occupying  the  cavity  of  the  tooth.  It  is  made  up  of  delicate  con- 
nective tissue,  in  which  ramify  the  dental  nerve,  artery,  and  vein. 

"  When,"  says  Mr.  Nasmyth,  "  the  internal  structures  of  a  dental  pulp  are 
examined,  the  number  of  minute  cells  which  present  themselves  in  avascular 
form  is  remarkable ;  they  seem,  indeed,  to  constitute  the  principal  portion  of 
its  bulk."  Mr.  N.  describes  them  as  "  varying  in  size,  from  the  smallest 
microscopic  appearance  to  one-eighth  of  an  inch  in  diameter  ;  and  as  being 
disposed  in  different  layers  throughout  the  body  of  the  pulp."  This  tissue  is 
highly  endowed,  and,  perhaps,  more  liable  than  any  other  portion  of  the  body 
to  take  on  morbid  action  ;  fungoid  degeneration  is,  perhaps,  its  second  most 
common  disease. 

Periodonteal  Membrane. — This  is  the  periosteum  of  the  tooth.  Anatom- 
ically and  physiologically  it  differs  little  from  this  general  class  of  membranes. 
Pathologically,  it  may  be  remarked  as  being  more  susceptible  to  disease,  and 
more  disposed  to  assume  quickly  the  acute  conditions.  For  example,  inflam- 
mation of  the  periodonteal  membrane  is  easily  provoked,  and,  once  inflamed, 
it  is  ever  after  surprisingly  prone  to  reassume  morbid  action.  Again,  we 
need  only  call  to  mind  its  epulic  outgrowths,  and  the  frequency  and  varied 
character  of  these  growths. 

Familiar  with  tooth  structure,  we  turn  to  Fig.  271,  and  trace  a  perversion 
of  development  in  all  these  structures, — see  them  forming  a  tumor,  strictly 
dental,  yet  to  the  last  degree  anomalous  and  abnormal. 

We  return  now  to  the  microscopic  examination  of  tumor,  made  by  Prof 
Ch.  Kobin,  Fig.  271  (400  diameters).  This  figure  represents  a  portion  of  a 
slight  cut  made  into  the  tumor  represented  in  Fig.  270,  a. 

The  preparation  is  taken  from  near  the  free  edge,  or  the  irregularly  mam- 


TUMOBS   OF   THE  MOUTH.  865 

molar  teeth  put  together.  He  need  scarcely  say  that  it  was  two  of 
the  molars ;  their  germs  had  in  some  way  affiliated,  and,  remaining 

millated  surface  of  the  tumor.  The  latter  is  formed  principally  of  the  ivory 
or  dentine,  easily  recognized  upon  the  thin  section  by  its  very  fine  tubes, 
disposed  in  parallels,  or  nearly  so,  through  part  of  their  extent  (Fig.  271,  e). 

These  tubes,  radiating  more  or  less  regularly  from  the  little  depressions  or 
cavities  observable  in  the  mass  of  the  tumor  (Fig.  270,  a),  very  near  to  each 
other  through  part  of  their  extent,  become  more  rare,  fine,  and  ramified 
as  they  approach  the  surfaces  of  the  dental  tumor  (Fig.  271,  d,f),  and  end 
in  a  very  sharp  point  toward  the  lines  of  junction  between  the  ivory  and  the 
enamel  (a,  b,  c),  and  the  cement  (/,  ff,  h).  The  presence  of  the  ivory,  which 
forms  the  greater  part  of  the  tumor,  demonstrates  its  dental  nature  very 
clearly. 

Enamel. — Another  important  particular  is  the  presence  of  the  enamel  on 
the  surface  of  the  tumor,  where  it  in  some  measure  covers  the  irregularities 
with  a  varnish  which  moulds  itself  upon  them  in  order  to  penetrate  more  or 
less  deeply  into  the  fissures  or  depressions  that  divide  the  tumor  superficially 
into  lobes. 

This  bed  of  enamel  varies  in  thickness  from  microscopic  dimensions  to  a 
millimetre  (.03937  inch),  or  near  it,  and  is  as  irregular  in  places  on  the  lower 
or  adhering  face  as  it  is  on  the  free  surface,  v/hich  the  microscope  alone 
allows  to  be  seen.  The  portion  of  the  section  of  the  tumor  that  is  here  de- 
lineated (Fig.  271)  is  taken  at  the  level  of  one  of  the  points  where  the  enamel 
(a,  b)  in  a  manner  penetrates  (c)  into  the  body  of  the  ivory  mass  of  which 
the  tumor  is  principally  formed. 

The  enamel  is  easily  recognized  by  its  narrow  prisms,  from  six-  to  eight- 
thousandths  of  a  millimetre  in  width,  which  are  in  immediate  juxtaposition 
(Fig.  271,  a,  b).  The  figure  shows  them  inclined,  as  by  the  accidents  of  the 
cuts  in  making  the  section.  When  the  cut  is  perpendicular,  or  nearly  so,  to 
their  grea>est  axis,  their  prismatic  form,  with  five  or  six  faces,  is  easily  seen  ; 
this  is  shown  in  the  neighborhood  of  5,  Fig.  271. 

Cemeitt. — In  the  depth  of  the  fissures,  and  here  and  there  in  the  mass  of 
the  tumor,  near  its  surface,  and  especially  that  part  of  the  surface  hidden  in 
the  adventitious  cavity  of  the  maxillary  bone,  the  mncroscope  discovers  some 
trails  or  beds  of  variable  thinness,  formed  entirely  of  the  substance  of  the 
cement  (Fig.  271,  g). 

The  cement  is  inclosed  betvyeen  masses  of  ivory,  and  is  consolidated  by  the 
immediate  contact  (Fig.  271)  with  the  masses  between  which  it  lies.  It  extends 
itself  in  places  with  the  surface  of  the  tumor  to  the  neighborhood  of,  and  even 
to  contact  with,  the  enamel.  The  section  represented  in  the  plate  is  taken  at 
a  point  that  shows  this  arrangement  (Fig.  271,/,  y,  h).  There  are,  besides, 
thin  pieces  of  cement  extending  far  forward  into  the  body  of  the  tumor. 

The  cement  is  known  to  be  no  other  than  the  osseous  substance.  The  figure 
before  us  exhibits  the  characteristic  elements  belonging  to  it.  These  are  the 
microscopic  cavities,  called  osteoplasts,  or,  incorrectly,  osseous  corpuscles,  for 
they  are  excavations.     The  air  that  fills  the  dry  bone  makes  these  cavities 

54 


866  ORAL   DISEASES  AND   SURGERY. 

encysted,  had  produced  this  abortion.  The  microscope  revealed 
very  distinctly  the  dental  character  of  the  mass,  pronouncing  it 
quite  as  distinctly  as  though  the  shapeless  lump  had  been  moulded 
to  the  tooth-form. 

The  author  has  had  shown  him,  as  great  curiosities,  teeth  with 
ivory  masses  projecting  at  right  angles  from  their  crowns.  He  never, 
however,  has  seen  this  anomaly  where  it  was  not  plainly  evident 

appear  black  under  the  microscope  (Fig.  271,  g)  ;  but  in  the  fresh  state  they 
are  full  of  liquid,  and  are  pale  and  more  difficult  to  observe  than  in  the  dry 
pieces. 

These  cavities,  which  are  in  breadth  and  length  from  one-  to  three-hun- 
dredths  of  a  millimetre,  are  always  of  very  irregular  shape,  on  account  of  the 
])resence  of  the  fine  tubes  that  start  from  all  their  peripheries  and  traverse 
even  the  substance  interposed  between  the  osteoplasts. 

The  best-joined  pieces  show  that  these  little  canals  are  subdivided  two  or 
three  times,  and  are  then  inosculated  with  those  of  neighboring  osteoplasts. 
The  portion  of  cement  shown  in  the  plate  does  not  exhibit  this  arrangement, 
which  was  visible,  nevertheless,  in  the  parts  close  to  it. 

The  cuts  in  the  tumor  exhibit,  moreover,  little  openings,  that  are  either  full 
of  a  grayish  or  brown  pus,  or  empty.  These  small  orifices  are  from  two-  to 
six-tenths  millimetre  and  upwards  in  width,  and  from  about  one  to  two  mil- 
limetres apart.  The  microscope  shows  that  these  orifices  accompany  the  nar- 
row, irregular  cavities,  sometimes  in  the  form  of  elongated  conduits,  hollowed 
out  of  the  ivory  through  which  they  pass.  The  instrument  also  shows  that 
the  tubes  of  the  latter  start  from  these  cavities  to  radiate  toward  the  surface 
of  the  tumor,  in  the  same  manner  as  the  tubes  of  the  ivory  in  the  normal 
tooth  start  from  the  natural  cavity  of  the  dental  pulp.  These  narrow,  irreg- 
ular cavities,  more  or  less  elongated,  traverse  the  mass  of  the  tumor,  and 
some  of  them  even  reach  within  a  few  millimetres  of  the  surface. 

These  cavities  are,  in  reality,  nothing  more  than  the  pulp-cavities  of  this 
morbid  product,  either  rugous  from  desiccation,  or  still  containing  some  rem- 
nant of  the  dried  pulp  in  the  form  of  a  brownish  or  grayish  powder. 

Kecapitulation. — The  result  of  all  these  observations  of  the  case  is  thus 
epitomized  by  M.  Forget : 

1st.  An  original  union  of  the  follicles  of  the  last  two  molars,  followed  by 
an  intimate  union  of  them,  caused  by  phlegmasial  or  other  action. 

2d.  Under  the  same  morbid  influence,  the  excess  of  vitality  in  the  organic 
elements  of  the  follicles  has  produced  hypersecretion  of  an  ivorj^-like  osseous 
substance. 

3d.  That  the  irregular  aggregation  and  diffusion  of  these  constitutes  the 
pathological  growth. 

4th  and  lastly.  Its  growth  has  formed  in  the  cyst,  and  it  ha?  maintained 
therein  a  permanent  inflammation  which  has  disorganized  the  osseous  tissue 
and  altered  the  structure  of  the  adjacent  soft  parts  to  such  an  extent  that  a 
radical  operation  was  necessary. 


TUMORS   OF   THE  MOUTH.  867 

that  the  projection  was  a  twin  tooth, — the  result  of  germ-union ; 
there  would  be  a  tooth  missing  in  the  arch. 

Many  curious  illustrative  instances  could  be  mentioned  of  anoma- 
lous incongruities  in  dental  evolution ;  but,  as  we  are  prepared  to 
understand,  we  would  find  them  in  character  the  same, — enamel, 
dentine,  cementum,  and  pulp  structure.  The  arrangement  only 
would  be  found  to  differ ;  with  our  eyes,  or  assisted  by  the  micro- 
scope, we  should  be  able  to  pronounce  concerning  any  of  them,  This 
is  dental. 

The  ability,  then,  to  distinguish  a  dental  from  a  malignant  osteoid 
tumor  must  certainly  prove  a  source  of  much  satisfaction  ;  for,  as  M. 
Forget  remarks,  if  intervention  cannot  be  too  radical  in  an  in- 
stance of  cancer,  it  is  certain,  on  the  contrary,  that  more  caution 
and  moderation  are  necessary  when  it  is  a  question  of  a  lesion 
which  is  essentially  local  and  of  a  benignant  nature,  and  allows  the 
surgical  operation  to  be  restricted  to  the  precise  limits  of  the  lesion, 
without  its  being  necessary  to  provide  against  an  improbable  repe- 
tition by  encroaching  upon  the  osseous  tissues  that  border  on  it, 
and  thus  subjecting  the  patient  to  a  mutilation  which  could  not  be 
justified. 

Data. — 1.  There  are  twenty  teeth  in  the  deciduous  denture,  which 
twenty  are  to  be  replaced  by  thirty-two,  each  of  which  is  to  be  at 
least  twice  the  size  of  its  predecessor. 

2.  A  contracted  maxilla,  having  no  accommodation  for  certain 
teeth,  the  germs  of  which  are  in  the  jaw,  gives  us,  among  other 
lesions,  irregularity  in  dental  evolution. 

3.  Irregularity  in  evolution  yields  morbid  conditions,  as  de- 
scribed, which  conditions  are  influenced,  not  unlikely,  by  peculiari- 
ties of  the  general  organization  and  manner  of  interference  with 
development. 

4.  An  overcrowded  arch  will  surely  yield  periodonteal  and  other 
minor  troubles,  and  may  produce  lesions  of  grave  character.  The 
extraction  of  certain  of  the  bicuspidate  teeth  of  the  permanent  set 
should  therefore  be  practiced,  whenever  time  shall  make  evident  the 
existence  of  contraction  on  the  part  of  the  arch. 

5.  Dental  tumors  vary  from  simple  cystic  growth  to  such  per- 
verse and  anomalous  evolutions  that  the  microscope  alone  is  capable 
of  explaining  them. 

6.  A  dental  tumor  is  an  abnormal  growth,  having  its  point  of 
departure  and  development  in  irregularity  of  dental  evolution. 

7.  Dental  tumors  are  benign ;  operations  for  their  cure  promise 


868  ORAL  DISEASES  AND  SUBGERY. 

all  success,  and  may  be  practiced  in  exclusive  consideration  of  the 
disease  as  it  locally  exists. 

8.  The  existence  of  a  dental  tumor  is  to  be  inferred,  cseteris  pari- 
bus, in  case  of  deficiency  and  derangement  in  the  dental  arch. 

The  existence  of  very  large  cysts,  as  occasionally  found  in  the 
lower  jaw,  involves  in  a  treatment  the  preservation  of  the  contour 
of  the  parts, — complete  section  of  the  bone  being  never,  as  a  pri- 
mary operation,  permissible.  Such  required  precaution  is  best 
secured  through  the  preparation  of  a  plate  fitting  the  teeth,  pre- 
cisely as  directed  for  fractures  when  the  inter-dental  splint  is  used. 
(See  Fractures.)  This  plate,  before  the  cyst  is  at  all  interfered 
with,  is  to  be  placed  in  position,  and  the  jaw  fixed  in  its  place.  This 
accomplished, — although  it  adds  to  the  inconvenience  of  the  treat- 
ment,— a  cyst  may  be  crucially  incised  and  stuffed  with  very  little 
danger  of  fracturing  the  continuity  of  the  parts.  Cysts  of  such 
delicate  attenuation  are,  however,  not  at  all  common,  a  consoli- 
dating and  supporting  periosteal  exudate  counterbalancing  to  a 
marked  extent  the  attenuation.  The  author,  at  the  present  time, 
has  under  treatment  a  cyst  of  the  lower  jaw  quite  the  size  of  an 
ordinary  orange,  yet  the  bone  seems  as  solid  as  iron.  The  patient 
in  this  instance,  however,  is  a  remarkably  vigorous  laboring  man. 

Cysts  may  have  a  self-explaining  origin,  yet,  from  the  presence 
of  a  systemic  vice,  depart  from  their  homologousness.  As  hetero- 
clitic  contents  are  met  with,  so  will  be  found  want  of  success  in 
attempts  at  cure  by  the  granulative  process.  The  septi  alluded  to 
as  seen  so  frequently  in  the  simple  cyst  will  be  found  at  times 
replaced  by  what  is  known  as  the  soft  multilocular  cyst.  Again, 
the  cavity  will  be  found  filled  with  a  pulpy,  liver-colored,  turgid 
mass.  It  has  been  the  experience  of  the  author  that  exactly  in  the 
degree  in  which  these  cysts  depart  from  simpJicity,  do  they  afford 
evidence  of  the  change  by  the  sympathy  expressed  in  the  overlying 
mucous  membrane.    (See  Cysto- Sarcoma.) 

In  accounting  for  the  formation  of  the  ordinary  dentigerous  cyst, 
the  hypothesis  has  been  advanced  that  the  condition  is  due  to  a 
morbid  secretion  into  and  enlargement  of  the  capsule  of  the  enamel 
organ :  this,  however,  is  certainly  not  the  explanation,  as  the  true 
enamel  membrane — the  tunica  propria — is  always  found  in  a  normal 
relation  and  position.  That  an  effusion  might  have  occurred 
between  the  enamel  and  its  matricial  membrane — the  tunica  reflexa 
— is  barely  probable,  although  possible ;  the  enamel  of  the  crowns  of 


TUMORS   OF  THE  MOUTH,  869 

the  encysted  teeth  being  commonly  too  perfect  to  warrant  inference 
of  interference  of  any  kind  in  the  process  of  development.* 

The  teeth  most  frequently  found  encysted  are  the  dentes  sapi- 
entiae  ;  this  would  be  inferred  from  the  relation  of  these  organs. 
After  the  wisdom-teeth,  the  next  in  frequency  are  the  euspidati. 
According  to  the  observations  of  Dr.  Bolles  (see  his  Prize  Essay), 
the  sexes  seem  nearly  equally  liable.  Most  of  the  instances  collated 
by  this  author  are  noticed  as  having  occurred  between  the  ages  of 
ten  and  forty  :  one  to  ten,  one  case  ;  ten  to  twenty,  nine  ;  twenty  to 
thirty,  nine ;  thirty  to  forty,  three  ;    forty  to  fifty,  none ;  fifty  to 

■^  "The  exciting  causes  are  often  unknown,  and  probably  various.  The 
attempts  of  the  impacted  teeth  to  reach  the  surface  have  an  exciting  action 
in  certain  cases  ;  but,  on  the  other  hand,  such  teeth  may  lie  quiet  in  the  jaw 
during  the  entire  life,  and  cause  no  trouble,  or  may  be  found  inclosed  in  a 
cyst  after  all  attempts  at  growth  had  been  given  up  for  years.  That  the 
disease  should  follow  the  extraction  or  aching  of  carious  teeth  is  not  remark- 
able, considering  how  common  these  are  at  all  ages ;  yet  such  irritation  in 
some  cases  may  have  been  the  exciting  cause  as  well  as  the  obstinate  resist- 
ance of  a  milk  tooth  to  the  advance  of  its  follower.  In  the  first  and  second 
cases  given  in  the  tables  the  disease  was  evidently  excited  by  the  blov/s  which 
preceded.  The  additional  presence  of  undeveloped  teeth  in  the  jaw  is,  of 
course,  essential  in  all  these  cases,  for  without  these  the  affection  cannot  exist. 

"  Whatever  may  have  been  the  exciting  cause,  the  pathology  is  essentially 
the  same.  The  disease  is  due  to  a  morbid  secretion  into  and  enlargement  of 
the  capsule  of  the  enamel  organ  of  the  unfortunate  tooth.  This  is  shown  by 
the  position  of  the  latter,  whose  crown  lies  exposed  in  and  to  a  certain  degree 
faces  the  cavity.  This  position  serves  to  distinguish  this  cyst  from  those 
instances  where  innocent  teeth,  before  eruption,  have  become  displaced  by 
the  growth  of  solid  or  even  fluid  tumors  in  which  their  own  enamel  organs 
bore  no  part,  or  other  cavities  which  simulate  it,  but  are  as  distinct  from  it 
as  hydrocele  from  scrotal  abscess.  If  the  fang  instead  of  the  crowji  project,  it 
is  not  a  true  dentigerous  cyst. 

"  Probably  the  reticular  parenchyma  of  the  enamel  organ  is  destroyed  by 
its  expansion,  but  in  the  multilocular  forms  this  may  possibly  aid  in  forming 
the  partitions.  The  whole  inclosure  is  lined  with  a  serous  membrane,  which 
is  sometimes  considerably  thickened  and  vascular,  and  continuous  over  the 
crown  of  the  tooth,  as  would  be  expected  from  its  origin.  A  microscopical 
examination  of  such  specimens  would  be  very  interesting ;  it  should  show  an 
absence  of  the  '  cuticula  dentis'  from  the  tooth  and  the  continuousness  of  its 
covering,  the  enamel  membrane,  with  the  rest  of  the  wall.  The  fluid  is 
usually  serous,  but  may  be  purulent, — contain  cholesterine,  flakes  of  lymph,  or 
shiny  matter,  or  vary  in  other  respects.  A  bony  exostosis  in  one  case  accom- 
panied the  cyst,  and  may  have  been  the  exciting  cause  of  it.  Other  compli- 
cations have  occurred." — Extract  from  a  Prize  Essaij  on  the  Deyitigerous  Cysts, 
by  W.  S.  BoLLES,  M.D. 


870  ORAL  DISEASES  AND   SURGERY. 

seventy,  three ; — the  duration  being  between  four  months  and 
thirty  years ;  the  lists  of  ages  being  at  time  of  operations. 

Dentigerous  cysts,  as  Would  be  inferred,  are  related  with  the 
permanent  (or,  as  they  would  in  this  connection  be  better  named,  the 
successional)  teeth.  One  or  two  exceptions,  however,  are  related : 
one  from  the  practice  of  Mr.  Alexander  Edwards,  of  Edinburgh,  being 
in  the  person  of  a  young  man  "in  whose  upper  jaw,  just  below  the 
orbit,  a  tumor  had  developed.  This  tumor  consisted  of  exostosis 
from  the  maxilla,  combined  with  a  bony  cyst,  containing  a  tooth 
which  was  pronounced  by  Prof.  Goodsir  to  be  a  temporary  molar." 

Of  the  various  preparations  in  existence  of  cysts  of  the  jaws,  the 
largest  with  which  the  author  is  familiar  is  one  in  the  Museum 
of  St.  George's  Hospital.  This  immense  tumor  rested  upon  the 
clavicle  when  the  head  of  the  patient  was  thrown  as  far  back  as 
possible.  This  tumor  may  be  found  figured  in  Holmes's  System  of 
Surgery,  vol.  iv.  p.  459. 

Cystiform  Antra. — Fig.  272  represents  a  cystic  tumor,  or,  rather, 
expansion  of  the  walls  of  the  antrum,  as  occasionally  met  with.  The 
cyst  represented  in  the  view  occurred  in  the  person  of  a  young- 
gentleman  some  twenty  years  of  age,  from  whose  jaw  it  was  re- 

-pjQ  272 Antral  ™oved  two  years  back.     This  cyst,  the  size  of  an 

Cyst.  ordinary  orange,  was  successfully  treated  with- 

out external  incision,  the  soft  parts  being  dis- 
sected off  by  pulling  outward  and  upward  the 
angle  of  the  mouth  ;  the  wall  of  the  cyst,  about 
the  thickness  of  ordinary  parchment,  was  cut 
away  with  a  chisel.  This  particular  cyst  was 
without  contents  of  any  kind.  After  the  removal 
of  the  vault,  the  soft  parts  were  permitted  to 
fall  into  the  cavity  of  the  sinus :  no  deformity 
resulted,  and  no  trouble  has  since  been  experi- 
enced. 

An  interesting  feature  in  this  character  of  cases 
is  found  in  the  tenacity  on  the  part  of  the  antrum,  after  operation, 
to  maintain  its  cavity.  The  author  has  tried  his  best  to  obliterate 
this  sinus  by  compelling  granular  activity  in  its  mucous  membrane, 
but  so  long  as  he  has  been  enabled  to  watch  cases  (and  in  one 
seven  months  elapsed  before  the  overlying  tissues  so  covered  in  the 
part  as  to  conceal  it  from  observation),  in  none  of  them  was  he  able 
to  satisfy  himself  as  to  what  was  the  subsequent  condition  of  the 


I 


TUMORS   OF  THE  MOUTH,  871 

sinus.  His  impression  is,  however,  that  the  mucous  membrane 
maintains  itself,  and  that  a  species  of  cavity  continues  to  exist. 

Hydrops  antri  is  another  form  of  cystiform  enlargement  of  this 
cavity.  The  dilatation  in  these  cases  is  gradual  and  painless,  and 
when  the  bone  becomes  expanded  to  any  considerable  extent, 
fluctuation  is  commonly  apparent,  the  vault  of  the  cyst  yielding 
readily  to  pressure.  If  any  obscurity  exists,  it  may  be  removed  by 
the  use  of  the  exploring-needle.  It  sometimes  happens  in  these 
cases  that  the  floor  of  the  orbit  becomes  the  yielding  point,  or  it 
may  be  the  canine  fossa,  the  tuberosity,  or  the  hard  palate ;  the 
latter  boundary,  however,  according  to  common  observation,  is  the 
most  frequent  seat  of  the  enlargement,  forming  the  tumor  within 
the  mouth. 

Hydrops  antri  depends,  in  many  cases,  on  the  formation  of  a 
cyst  within  the  cavity.  In  others  it  may  be  viewed  as  a  simple 
mucous  engorgement,  the  natural  outlet  into  the  meatus  being, 
from  some  cause  or  other,  obliterated.  A  very  expressive  illus- 
tration of  the  first  of  these  conditions  was  exhibited  in  a  specimen 
taken  some  three  years  back  from  the  antrum  of  a  young  man.  In 
this  case  the  cyst  seemed  to  spring  from  the  root  of  the  second 
molar  tooth,  or  its  immediate  neighborhood ;  the  mucous  membrane 
had  been  dissected  up,  and  covered  the  cyst  as  a  reflex  tunic.  Al- 
though this  particular  tumor  was  not  large  enough  to  exhibit 
external  evidence  of  its  existence,  yet  there  are  no  reasons  for  infer- 
ring that  such  tumefaction  would  not  eventually  have  resulted.  A 
case  of  Interest  in  this  direction  is  recorded  in  the  practice  of  Dr. 
Chase,  of  Iowa  City,  who  reports  it  in  the  Dental  Cosmos,  accom- 
panying the  report  with  a  diagram.* 

*  Description  of  Case. — "An  Irishwoman,  aged  forty  years,  came  to  have 
the  right  first  upper  molar  extracted.  I  found  her  teeth  in  a  bad  condition 
generally:  they  were  decayed  and  loose,  and  the  gums  congested.  This  par- 
ticular tooth  was  decayed  and  very  loose.  On  pressing  it,  the  alveolus 
seemed  to  move  with  the  tooth.  Adjoining  it  in  front  was  the  root  of  the 
second  bicuspid, — the  crown  gone. 

"  As  she  was  of  that  class  who  make  no  attempt  to  preserve  their  teeth,  I 
extracted  the  molar  without  hesitation.  She  had  told  me  that  her  'jaw'  had 
ached  for  three  or  four  months  previous  to  this  time.  On  applying  the  for- 
ceps, the  beaks  readily  passed  under  the  gums  without  lancing,  and  the  tooth, 
much  to  my  surprise,  came  away  with  a  very  slight  application  of  force.  But 
this  surprise  was  not  equal  to  my  astonishment  when  I  saw  what  I  had 
brought  away  with  the  tooth, — namely,  a  large  quantity  of  alveolar  substance, 


872 


ORAL  DISEASES  AND   SURGERY. 


M.  Giraldes  describes  multiple  cysts  of  the  antrum  ranging  in 
size  from  a  pea  to  a  pigeon's  eg^.     These  cysts  he  illustrates  as 


the  bicuspid  root,  and  a  fibrous  connective-tissue  tumor,  nearly  an  inch  in 
diameter,  attached  to  the  tooth,  and  inclosing  two  of  the  roots,  namely,  the 
posterior  buccal  and  the  palatine  root. 

Fig.  273. — Secondary  Cyst  of  the  Antrum.  . 


1,  root  of  second  bicuspid  attached  to  alveolus ;  2,  neck  of  tooth  and  border  of  alveolus ; 
3,  walls  of  antrum,  palatal  side  ;  4,  centre  of  crown  of  tooth  ;  5,  tumor ;  6,  tartar,  cover- 
ing the  cavity  of  decay.  The  buccal  aspect  of  the  tooth  was  similar  in  appearance  to  the 
palatal  surface  which  is  seen  in  the  engraving. 

"  After  being  in  alcohol  three  days,*  the  tumor  was  nearlj^  white,  and  had 
shrunken  to  one-third  its  original  size.  On  cutting  it  open,  it  was  found  filled 
with  a  solid  structure.  The  consistence  was  that  of  tubercle,  or  pressed  cheese- 
curd  ;  the  color,  light  yellow,  tinged  in  most  parts  with  red. 

"The  roots  within  the  tumor  were  nearly  free,  and  covered  with  their 
periosteum,  which  had  thickened  into  a  loose,  spongy  mass,  extending  even 
to  the  base  of  the  body  of  the  tooth.  The  appearance  was  like  that  of  roots 
involved  in  alveolar  abscess.  The  walls  of  the  tumor  were  not  composed  of 
detached  dental  periosteum.  There  were  apparently  two  coats,  the  outer 
fibrous,  like  periosteum  ;  the  inner  a  mucous  one,  like  the  lining  of  the  nasal 
cavity." 

The  pathology  of  the  case,  as  inferred  by  Dr.  Chase,  is  that  the  tooth 
decayed  to  the  pulp-cavity,  and  that  the  pulp,  after  repeated  inflammatory 
attacks,  died.  Putrefaction  of  that  organ  occurred,  provoking  periodontitis  ; 
after  awhile  suppuration  occurred,  and  the  disease  became  chronic.  The  perio- 
donteum  became  thickened  and  spongy,  and  continued  irritation  caused  a 
proliferation  of  connective-tissue  corpuscles,  thus  eventuating,  finally,  in  the 
formation  of  the  cyst. 

This  inference  is,  probably,  the  true  explanation  of  the  cyst.  The  trouble, 
however,  seems  to  have  been  seated  primarily  upon  the  bicuspis  and  not  upon 
the  molar  roots, — involving  the  latter  secondarily.     This  tumor,  although  it 


*  It  is  to  be  regretted  that  an  examination  was  not  made  at  once. 


TUMORS  OF  THE  MOUTH.  873 

being  found  filled  with  a  fluid  sero-albuminous,  thin  or  glairy,  and 
diflfering  in  color  in  different  eases,  being  brown,  yellow,  or  blood- 
color.  The  suppuration  of  these  cysts  is  described  as  the  occa- 
sional cause  of  resisting  abscess.  These  cysts  this  author  believes 
to  be  quite  common,  and  that  they  are  the  cause  of  many  of  the 
enlargements  encountered.  Their  origin  he  locates  in  morbid 
changes  of  the  mucous  glands.* 

possessed  not  the  contents  of  the  one  operated  on  by  the  author,  has  a  similar 
pathological  signification  :  it  constitutes  an  instructive  example. 

In  cases  of  this  kind  it  will  be  seen  at  a  glance  that,  however  patulous  the 
natural  outlet  might  be,  the  contents  of  the  tumor  could  not  by  such  means 
find  egress.  In  the  second  character  of  cases,  the  contents  are  just  within  the 
cavity,  but  the  engorgement  of  the  tissue  bounding  the  outlet  has  closed  the 
foramen.  A  case  described  in  the  chapter  on  Diseases  of  the  Antrum  exhibits 
the  dangerous  and  destructive  efl'ects  of  such  accumulations  when  unappreciated 
and  untreated. 

*  Recherches  sur  les  Kystes  muqueux  du  Sinus  maxillaire. 


CHAPTER    XLir. 

THE  TUMORS  OF  THE  MOUTH. 

NON-EXPLAINABLE    TUMORS. 

So  far  we  have  studied  tumors  of  the  jaws,  all  of  which,  with 
the  exception  of  certain  of  the  epulides,  we  must  feel  are  fully  known 
to  us  through  a  self-explanation  which  we  have  seen  to  reside  in 
them.  From  these  we  pass  to  our  second  classification ;  premising 
that,  as  a  growing  intelligence  and  experience  may  be  able  solidly 
to  explain  certain  of  them  from  the  local  stand-point,  so  it  shall  be 
the  good  office  of  him  who  explains  to  modify  the  present  classifi- 
cation.* 

*  "  In  regard  to  ihep7'ognosis  and  course  of  tumors,  from  what  has  been  said 
you  may  infer  :  1.  That  they  seldom  recover  spontaneously,  nor  are  they 
accessible  to  medicines  ;  and,  2.  That  they  are  partly  infectious,  partly  not 
so.  The  latter  point  is  particularly  striking  to  unprejudiced  observation. 
There  are  some  tumors  which  do  not  return  after  extirpation,  and  others  that 
not  only  return  in  the  cicatrix,  but  come  in  the  neighboring  lymphatic  glands 
and  also  in  internal  organs,  as  already  remarked.  The  former  have  for  ages 
been  called  benignant,  the  latter  malignant  or  canceroizs.  This  observation  is 
so  simple  that  it  would  seem  merely  necessary  to  study  exactly  the  peculi- 
arities of  one  or  other  form  of  tumor,  to  arrive  at  an  accurate  prognosis. 
But  accurate  clinical  and  anatomical  study  did  not  lead  to  this  desired  simple 
result  of  this  dualism,  but  it  showed  that  the  latter  did  not  exist,  that  the 
conditions  were  more  complicated.  After  an  exhaustive  anatomical  study  and 
description  of  benignant  and  malignant  growths,  they  were  examined  undt-r 
the  microscope  and  in  the  retort ;  it  was  thought  that  the  characteristic  marks 
had  been  found  now  in  one  point  now  in  another,  and  soon  one  discovery  after 
another  proved  erroneous:  it  was  thus  shown  that  an  antithesis  of  absolute 
malignancy  and  benignancy  did  not  exist  in  the  sense  meant,  and  that  it  was 
necessary  to  distinguish  not  only  solitary,  multiple,  and  infectious  tumor.-, 
but  that  a  scale  must  also  be  made  in  the  grade  of  infectiousness.  We  must 
investigate  this  more  closely.  We  call  a  tumor  solitary  when  only  one  occurs 
in  the  body  and  causes  purely  local  symptoms;  they  are  usually  growths  con- 
sisting of  any  fully-developed  tissue, — fibroma,  chondroma,  osteoma,  etc.  We 
(874) 


TUMORS  OF   THE  MOUTH.  875 

The  tumors  now  to  be  described  are  found  to  be  so  variously  classi- 
fied by  various  authors,  that  any  one  fairly  qualified  mav  feel  him- 

speak  of  multiple  tumors  when  a  series  of  similarly-organized  growths  occur 
only  in  one  certain  system  of  tissue  ;  for  instance,  when  numerous  chondro- 
mata  occur  only  on  bones,  or  numerous  lipomata  only  in  the  subcutaneous 
cellular  tissue,  or  many  fibromata  only  in  the  skin,  etc.  As  generally  acknowl- 
edged, there  is  at  the  same  time  a  predisposition,  which  Virchow  regards  as 
purely  local,  but  which,  as  already  stated,  I  must  consider  constitutional.  In 
general,  we  may  say  that  all  sorts  of  tumors  may  occur  as  solitary  or  multi- 
ple, although  the  latter  is  very  rare  in  some  forms  of  tumors.  We  apply  the 
term  hifectiozis  to  a  tumor  which  not  only  grows  into  the  parts  around  it, 
infiltrating  them  and  thus  constantly  growing  by  apposition  of  new  foci,  but 
which  may  also  infect  the  next  lymphatic  glands  and  finally  other  organs. 
In  this  respect  there  are  very  great  differences  :  in  some  tumors  the  infection 
extends  regularly  only  to  the  next  lymphatic  glands  (carcinoma  of  the  lips  and 
face)  ;  in  other  cases  from  that  point  it  extends  farther,  especially  to  internal 
organs  (carcinoma  of  the  breast)  ;  lastly,  infection  of  the  entire  body  with 
metastatic  tumors,  without  infections  of  the  lymphatic  glands,  sometimes 
occurs  (some  forms  of  sarcoma).  Moreover,  the  rapidity  with  which  infec- 
tion follows,  varies  greatly.  If  we  examine  the  conditions  under  which 
infectious  tumors  develop,  and  their  anatomical  structure,  we  shall  see  that 
they  occur  especially  in  advanced  age,  about  equally  in  men  and  women,  and 
particularly  often  in  certain  organs  ;  that  the  age  of  childhood  is  disposed  to 
infectious  growths,  especially  to  malignant  sarcomata,  while  in  j'outh  and  the 
first  years  of  adult  age  very  few  tumors  of  any  kind,  and  especially  few  malig- 
nant tumors,  develop.  Mode  of  life,  good  or  bad  food,  poverty,  riches,  char- 
acter, nationality,  and  cultivation,  appear  to  have  no  special  influence  on  the 
development  of  tumors  generally  ;  nor  can  we  recognize  any  specific  influ- 
ence of  these  powers  on  infectious  tumors.  The  study  of  the  anatomical 
structure  of  tumors  has  been  pursued  with  great  zeal  of  late,  and  it  appears 
that  a  large  number  of  malignant  growths  have  characteristic  macroscopic 
and  microscopic  peculiarities,  but  that  a  correct  prognosis  cannot  always  be 
based  on  them ;  in  general  we  may  say  that  they  are  usually  very  vascular 
tissue-formations,  disposed  to  ulceration,  and  in  their  course  proving  to 
be  infectious.  As  it  is  most  probable  that  the  infection  results  from  the 
locomotion  of  specific  tumor-elements,  some  of  the  factors  relative  to  reab- 
sorption  may  here  have  some  eff"ect.  The  quantity  of  blood  and  lymphatic 
vessels  in  the  tumor  and  its  immediate  vicinity,  the  conditions  influencing 
opening  and  closure  of  these  passages,  and  the  activity  of  the  circulation 
generally,  are  to  be  considered. 

"  Infectious  tumors  are  usually  at  first  solitary,  very  seldom  multiple  in  the 
sense  above  indicated.  Tumors  that  are  multiple  from  the  start  are  rarely  infec- 
tious. When  we  use  the  terms  dangerous,  malignant,  and  infectious,  as  synony- 
mous, we  do  so  without  regard  to  the  locality  where  the  tumors  are  developed. 
A  solitary  benignant  tumor  in  the  brain  is  always  malignant,  from  its  locality  : 
an  infectious  tumor  at  the  same  point  possibly  never  goes  beyond  local  infec- 


876  OBAL  DISEASES  AND  SURGERY. 

self  excused  in  marking  out  what  to  his  own  mind  may  seem  a 
simplification  of  the  subject,  —  simplification  being  the  common 
object  with  all  writers. 

In  a  record  of  307  cases  of  tumors  of  the  jaws  made  by  Prof. 
C.  Weber,  the  histological  variety  exhibited  was  as  follows :  Car- 
cinoma, 133;  sarcoma,  84;  osteoma,  32;  cystoma,  20;  fibroma, 
It ;  enchondroma,  8;  gelatinoid  polyps,  T  ;  melanotic  sarcoma  and 
carcinoma,  5;  angeioma,  1. 

Upon  such  a  record  it  would  seem  that  in  all  solidity  a  classifi- 
cation might  be  founded.  This  indirectly  we  may  accept;  directly, 
however,  it  is  not  a  matter  that  concerns  us.  Our  classification  is  to 
recognize  but  a  single  condition, — we  here  exclude,  for  convenience, 
any  expression  that  might  be  met  with  of  syphilis,  scrofula,  or  tuber- 
culosis,— conditions  that  any  surgeon  would  recognize, — a  condition 
of  many  expressions,  these  expressions  being  accorded  the  title  of 
destructive  diseases  by  C.  Weber  and  those  who  follow  that  mode 
of  classification.  Indirectly,  however,  we  must  accept  a  histologi- 
cal classification,  as  thus  with  most  convenience  we  may  find  data 
for  a  study,  the  understanding  of  which  is  of  the  greatest  service, 
and  certainly  of  the  greatest  interest. 


tion,  as  it  soon  proves  fatal,  /ill  these  things  are  to  be  carefully  weighed,  if 
we  would  obtain  clear  ideas  on  these  points. 

"  Tumors  are  not  always  to  be  termed  infectious  (malignant,  cancerous) 
because  of  a  return  at  the  point  cf  operation.  In  this  case  it  is  very  impor- 
tant to  decide  whether  the  recurring  tumor  has  started  from  portions  of  the 
original  tumor,  that  have  been  left  at  the  time  of  operation  (continuous 
recurrence,  Thiersch),  or,  possibly  years  after  a  perfect  operation,  a  new  tumor 
has  occurred  from  similar  causes  in  the  cicatrix  or  in  its  vicinity  (regional 
recurrence).  If  the  point  of  operation  remains  free,  and,  after  the  operation, 
swellings  of  the  lymphatic  glands,  of  the  same  nature  as  the  extirpated  tumor, 
appear,  or  if,  under  similar  circumstances,  v/ithout  swelling  of  the  lymphatic 
glands,  growths  occur  in  other  organs,  it  may  be  considered  certain  that  these 
lymphatic  glands  and  other  organs  were  already  infected  at  the  time  of  opera- 
tion, although  this  may  not  have  been  susceptible  of  proof  on  examination. 

"  When  a  person  is  infected  from  a  tumor,  we  term  it  a  dyscrasia,  just  as 
we  do  when  one  is  infected  from  a  focus  of  inflammation.  In  such  persons 
foreign  materials  circulate  in  the  fluids  of  the  body,  inducing  in  them  a  patho- 
logical condition.  In  infectious  tumors  this  dyscrasia  displays  itself  by  general 
disturbance  of  the  nutrition, — emaciation,  marasmus  ;  how  soon  and  how  ex- 
tensively this  shall  occur  depends  very  essentially  on  the  seat  of  the  tumor 
and  its  peculiarities  (softening,  becoming  gangrenous,  ulceration,  bleeding, 
etc.),  as  well  as  on  the  strength  and  age  of  the  patient." — Billroth. 


TUMOBS   OF   THE  MOUTH.  877 

First.  Fibrous  Tumors — Fibroma. — The  study  of  the  fibromata 
begins  with — 1.  A  tumor,  the  most  common  seat  of  which,  as  the 
whole  body  is  concerned,  is,  beyond  comparison,  about  the  jaws. 
These  tumors,  which  to  the  eye  are  composed  of  firm,  interlaced 
fibrous  tissue,  are,  to  the  touch,  hard,  yet  to  an  extent  elastic. 
Such  growths  spring  from  the  periosteal  tissue,  and  find  a  favorite 
location  in  the  antrum.  When  unmoulded,  as  when  springing 
from  a  free  surface,  they  are  superficially  lobed,  and,  as  a  rule, 
are  ovoid  in  form  ;  when  occupying  the  sinus,  they  conform  very 
much  to  the  shape  of  the  cavity,  and  are  apt  to  retain  the  bony 
covering  until  they  attain  a  size  many  times  greater  than  the  site 
from  which  they  originate.  In  color,  these  tumors  are  a  faintly  yel- 
lowish white,  pure  white,  or  a  very  pale  red ;  in  arrangement,  the 
fibres  are  concentrically  related,  affording  an  expression  of  concen- 
tration, as  if  growing  toward,  rather  than  from,  a  centre. 

The  diagnosis  of  this  form  of  the  fibromata  lies  in  the  isolation 
of  the  growth  ;  in  its  elastic  hardness  ;  in  the  perfectly  healthy  and 
non-implicated  appearance  of  the  associate  parts ;  in  the  absence  of 
pain;  and  in  the  tardy  growth.  Such  a  tumor  is  to  be  removed  with 
an  almost  positive  assurance  of  non-return. 

2.  A  second  form  of  the  fibromata  is  found  in  such  close  alliance 
with  the  first  that  no  one  might  doubt  the  intimate  relationship  of 
the  two,  differing  really  alone  from  the  first  in  the  presence  of  a 
looser  stroma,  being  what  Rindfleiscb,  in  his  classification,  would 
term  "  a  connective-tissue  tumor."  This  tumor,  or  rather  this  ex- 
pression of  a  common  tumor,  has  not  the  same  concentric  develop- 
ment, seeming,  in  this  respect,  to  be  less  resisted  by  the  neighboring 
parts  ;  it  does  not  infiltrate,  but  yet  is  of  eccentric  rather  than  con- 
centric growth  ;  or,  if  not  this,  then  the  fibrous  relation  is  irregular. 
This  is  the  first  exprescior;  of  ihe  fibro-plastis  tumor  of  Lebert. 

3.  The  myomata  of  Virchow.  Adrancing  one  step  farther  in 
the  appreciation  of  the  fibromata,  we  meet  with  those  spindle-shaped 
cells,  which  induced  Yirchow  to  give  to  the  expression  the  name  of 
myoma,  and  which,  when  possessed  of  more  marked  characteristics, 
constitute  the  fibro-sarcoma  of  Rokitansky.  This  is  the  fibro-re- 
curring  tumor,  an  expression  of  which  Mr.  Miller  speaks — see  his 
"  Principles  of  Surgery" — "  as  of  a  tumor  ill  defined,  one  which  it 
may  be  doubted  if  it  is  not  more  properly  classed  when  placed  among 
the  malignant  condition,  seeing  they  are  found  prone  to  return,  after 
excision,  with  singular  obstinacy." 

The  eccentric  fibrous  tumor — fibro-plastic,  fibro-recurring,  myoma. 


878  OKAL  DISEASES  AND   SURGEBY. 

fibro-sarcoma — presents  alterations  of  structure,  from  whieb,  at  a 
point  unknown  to  tbe  autbor,  it  passes  into  classification  as  sarcoma. 
Second.  Sarcoma. — Tbe  sarcomata  are  so  called  from  presenting 
on  section  a  flesby  look.  A  pure  myoma  would  be  alone  tbe  sarcoma, 
If  by  flesb-like  we  meant  muscle-like  ;  but  by  flesb-like  bas  not  been 
meant  muscle-like  ;  bence  to  say  wbat  is  and  wbat  is  not  a  sarcoma, 
is  with  all  writers  merely  an  approximation.  With  such  confusion — 
exposed  in  detail  in  tbe  first  edition  of  this  work — our  classification 
happily  enables  us  to  dispense.  A  sarcoma  is  wbat  in  that  volume 
it  was  designated,  and  wbat  it  is  now  designated  by  Billroth, — "  a 
tumor  consisting  of  tissue  belonging  to  tbe  developmental  series  of 
connective-tissue  substances  (connective  tissue,  cartilage,  bone), 
muscles,  and  nerves,  which,  as  a  rule,  does  not  go  on  to  the  formation 
of  a  perfect  tissue,  but  to  peculiar  degenerations  of  tbe  develop- 
mental forms;"  in  other  words,  it  is  an  expression  of  the  fibromata. 
Rindfleisch  distinguishes  the  sarcomata  into  "  the  round-celled 
sarcoma,  the  spindle-celled  sarcoma,  and  tbe  fibroma."* 

*  "  The  granulation-like  round-celled  sarcoma  (sarcoma  globo-cellulare  sim- 
plex) in  its  textural  and  structural  relations  is  allied  to  the  model  of  the 
tissue  of  granulations.  To  the  naked  eye,  a  yellowish  or  reddish,  thoroughly 
homogeneous,  elastically  soft  mass,  at  times  extraordinarily  like  the  roe  of 
fishes,  presents  itself  from  the  cut  surface;  by  scraping  with  a  knife-blade, 
we  can  obtain  a  scanty  amount  of  juice,  which  is  almost  entirely  clear,  or 
contains  but  few  cells.  The  cells  are  small,  round,  and  contain  comparatively 
large  nuclei,  of  sharp  contour,  and  provided  with  nucleoli.  The  protoplasm, 
as  a  rule,  is  present  only  in  small  amount,  therewith  entirely  naked  ;  we 
must  have  recourse  to  hardening  the  tumor  and  coloring  it  with  carmine,  in 
order  to  make  it  generally  distinct,  and  to  convince  ourselves  that  a  cell-body 
actually  belongs  to  each  of  the  apparently  free  nuclei. 

"  The  structure  of  round-celled  sarcoma  deviates  only  in  a  quantitative  rela- 
tion from  the  structure  of  granulations.  The  vessels  in  part  are  wider,  thicker 
walled  ;  where  these,  however,  break  up  into  capillaries,  they  are  just  as  deli- 
cate, frequently  only  built  of  a  simple  cell-layer,  such  as  we  saw  in  the  vessels 
of  granulations.  The  interspaces  between  the  vessels  are  everywhere  uni- 
formly filled  by  the  round  cells  and  the  scanty,  soft,  and  formless  basis-sub- 
stance of  the  germinal  tissue.  In  rare  cases  one  observes  a  higher  organization 
of  the  whole,  which  reminds  of  the  papillosities  of  granulations,  namely,  a 
radiated  striation  and  a  decided  disposition  of  the  mass  of  the  tumor  for  cleav- 
ing in  radiating  directions.  We  will  more  intimately  speak  of  this  fascicu- 
lated round-celled  sarcoma,  which,  by  preference,  proceeds  from  periosteum, 
at  the  proper  time,  as  sarcoma  ossificum. 

"  The  simple  round-celled  sarcoma  proceeds  most  frequently  from  connect- 
ive-tissue membranes  :  the  periosteum  and  the  sheaths  of  the  nerve-centres  are 
its  favorite  situations;  meanwhile,  we  must  also  be  prepared  occasionally  to 


TUMORS   OF   THE  MOUTH.  879 

Another  expression  of  this  tumor  is  that  classified  and  described 
by  Mr.  Paget  as  the  myeloid, — so  called  from  a  resemblance  to  mar- 
meet  it  in  other  parts,  especially  upon  the  outer  skin,  upon  mucous  and  serous 
membranes,  even  in  glands.  The  simple  round-celled  sarcoma  is  closely 
allied  to  the  small-celled  spindle-celled  sarcoma,  and  through  this  to  fibroma, 
and  manifoldly  goes  over  into  it.  To  this  corresponds  the  relative  benignity 
which  marks  just  these  tumors  above  all  other  round-celled  sarcomas. 

"  The  lymphatic  gland-lihe  roicnd-celled  sarcoma  (sarcoma  lymphadenoides 
moUe)  owes  its  more  limited  consistence  pre-eminently  to  the  circumstance 
that  its  cellular  elements  are  less  intimately  and  immediately  combined  with 
each  other  than  the  cells  of  ordinary  tissue  of  granulations.  We  can  here 
obtain  with  facility,  by  scraping  the  cut  surface,  a  juice  with  an  abundance 
of  cells,  whose  microscopic  observation  shows  these  latter  to  be  round  cells, 
which  are  distinguished  by  large,  oval,  slightly  refractive  nuclei,  provided 
with  one  dot-like  nucleolus.  If  we  harden  the  tumor  and  tease  out  a  thin 
section  of  it,  we  find  between  the  cells  a  delicate  intercellular  net-work,  which 
strongly  reminds  of  the  reticulum  of  the  lymphatic  follicles,  the  intestinal 
mucous  membrane,  and  caro  luxurians  (proud  flesh).  This  net-work  spreads 
itself  among  the  wide,  thin-walled  capillaries,  and  gives  the  whole  structure 
a  certain  support,  while  on  the  other  hand  it  permits  the  accumulation  of  an 
abundance  of  fluid  beside  the  cells,  and  favors  the  isolation  of  the  latter. 

"  The  sarcoma  under  consideration  most  frequently  proceeds  from  the  sub- 
cutaneous, subfascial,  and  intermuscular  connective  tissue  of  the  thigh.  In 
the  next  place,  the  lymphatic  glands  must  be  designated  as  its  preferred  situ- 
ation. Here,  however,  the  peculiar  case  occurs,  that  the  uniformity  of  struc- 
ture could  cause  anatomists  to  regard  sarcoma  as  a  hyperplasia,  though  ever 
so  monstrous,  of  lymphatic  glands,  while  yet  the  clinical  character  (malig- 
nancy of  high  degree)  exhibits  a  complete  uniformity  with  the  soft  sarcoma. 

"  There  are  several  varieties  of  lymphadenoid  sarcomas.  The  lipomatous 
sarcoma  (sarcoma  lipomatodes)  shows  the  peculiarity  that  its  cells  are  trans- 
formed into  fat-cells  by  the  infiltration  of  fat.  This  transformation  always 
aff'ects  only  a  limited  number  of  the  existing  elements;  as,  however,  the 
sheen  and  size  which  the  single  cells  attain  deceive  the  eye,  it  may  readily 
have  the  appearance  as  though  at  least  the  great  majority  of  the  sarcoma-cells 
had  become  fat-cells.  Of  any  considerable  similarity  to  genuine  adipose  tissue 
there  can,  nevertheless,  not  a  word  be  said  ;  the  want  of  uniformity  of  infil- 
tration, and  the  circumstance  that  we  find  very  small  and  very  large  fat-cells 
confusedly  intermingled  and  never  united  into  little  clusters,  exclude  all 
mistake  for  lipoma. 

"  The  mucoid  sarcoina  (sarcoma  myxomatodes).  It  is  a  tolerably  frequent 
occurrence  to  see  here  and  there  small  portions  of  mucoid  tissue  in  round- 
celled  sarcomas.  A  translucent  gelatinouslj'^  trembling  consistency  betrays 
places  of  this  kind  already  to  the  naked  eye  ;  the  microscope,  as  a  rule,  exhibits 
an  abundant  quantity  of  mucoid  basis-substance,  with  numerous  round,  non- 
anastomosing  cells  imbedded.  The  mucoid  softening  of  the  basis-substance 
may  be  properly  regarded  as  a  secondary  metamorphosis,  to  which  all  round- 


ORAL  DISEASES  AND  SURGERY. 

row, — an  expression  so  lacking  a  persistent  individuality  that,  even 
according  to  the  classifier  himself,  they  vary  from  simple  semi-fibrous, 
serai-marrow-like  structure  to  those  so  heteroclitic  that  they  seem 
to  merge  into  the  medullary. 

celled  sarcomas  are  disposed.  In  as  far,  however,  as  this  begins  at  an  early- 
period  and  extends  over  greater  sections  of  a  tumor,  is  the  name  '  mucoid 
sarcoma'  justifiable.  Nay,  the  mucoid  tissue  may  so  predominate,  that  we 
might  be  tempted  to  think  of  a  completely  mucoid  tumor,  a  myxoma,  if  yet 
some  unchanged  places,  especially,  however,  the  young  developments  at  the 
periphery  of  the  tumor,  and  striking  metastases,  did  not  place  its  sarcomatous 
nature  beyond  doubt.  An  exceedingly  rapid  growth,  which  is  said  to  pertain 
to  mucoid  sarcomas,  may  be  illusively  presented  by  this,  that  the  mucus, 
because  of  its  extraordinary  capacity  for  swelling  up,  occupies  a  far  larger 
space  than  does  the  scanty  basis-substance  of  the  sarcoma. 

"  Mucoid  metamorphosis  and  fatty  infiltration  not  infrequently  occur  side 
by  side,  and  just  these  tumors  may  attain  a  colossal  volume. 

"  Besides  the  loose  connective  tissue  of  the  extremities,  the  subperitoneal 
connective  tissue  is  also  a  favorite  seat  of  mucoid  sarcoma. 

"  The  large-celled  round-celled  sarcoma  shows  us  an  almost  epithelial  struc- 
ture of  cells,  besides  a  correspondingly  large-meshed  intercellular  net.  This 
tumor  is  very  soft,  like  the  white  matter  of  the  brain,  and  is,  therefore,  easily 
mistaken  for  the  following  species. 

"  The  alveolar  round-celled  sarcoma,  Billroth  (sarcoma  medullare  carcino- 
matodes)  represents  a  further  advance  in  the  independence  of  the  cells,  which, 
upon  the  one  hand,  may  be  compared  to  the  suppuration  of  an  inflammatory 
texture;  upon  the  other,  however,  reminds  of  that  sharply-defined  opposition 
between  connective-tissue  parts  and  the  cellular  apparatus,  which  we  find  in 
cancer.  Characteristic  of  these  forms  is  the  occurrence  of  roundish  balls  of 
cells,  which  are  no  longer  connected  together  by  a  proper  basis-substance,  but 
are  taken  up  by  a  correspondingly  large  cleft  in  the  continuity  of  connective 
tissue,  like  the  pus-corpuscles  in  a  small  abscess.  It  is  not  said  therewith 
that  these  cells  are  also  externally  like  pus-corpuscles  ;  they  are  rather  con- 
siderably larger,  have  vesicular,  round  nuclei,  with  bright  nucleoli;  and  in 
this  respect  they  approach  more  nearly  to  the  epithelial  condition,  which,  in 
individual  cases,  they  even  deceptively  imitate.  I  esteem  this  of  more  con- 
sequence then  is  conceded  to  me  at  many  hands,  because  I  straightway  pro- 
nounce the  formation  as  a  carcinomatous  degeneration  of  the  sarcoma  (sarcoma 
carcinomatodes).  According  to  my  judgment,  we  must  no  longer  hold  to  the 
opinion  that  the  carcinomatous  structure  which  presents  tha  clinical  charac- 
ters of  carcinoma  exclusively  proceeds  from  the  preformed  division  between 
connective  tissue  and  epithelium.  '  Stroma'  and  '  cellular  deposition'  may 
also  be  produced  in  other  ways,  and  'epithelioid'  is  not  yet  'epithelium,' 
although  one  might  form  conjectures  as  to  why  those  cells,  which  loosen 
themselves  in  a  more  organic  manner,  slowly,  and  not  suddenly,  like  pus-cor- 
puscles, from  the  mother-soil,  always  show  this  tendency  to  a  more  epithelial 
development.     For  this  is  just  the  difference  between  an  actual  suppuration 


TUMORS  OF   THE  MOUTH.  881 

"A  myeloid,"  says  Mr.  Paget,  "like  afibrons  tumor,  maybe  either 
inclosed  in  a  bone  whose  walls  are  expanded  round  it,  or,  more 

and  this  imitation,  that  at  the  present  time  we  have  yet  no  right  to  regard  the 
cell-balls  mentioned  as  elements  complelelj'  separated  from  the  nutrition  of 
the  body.  Their  longer  continuance  without  fatty  degeneration  gives  us 
security  for  this. 

"Sarcoma  carcinomatodes  occurs  at  the  most  various  points  of  the  inter- 
mediary nutritive  apparatus,  most  frequentlj'^  in  the  medulla  of  bone,  in  the 
eye,  in  the  subcutaneous  tissues.  An  exceedinglj'  malignant  variety  of  this, 
distinguished  by  the  pigment  contained  in  its  cells,  is  the  so-called  pigmentary 
cancer  (sarcoma  alveolare  pigmentatum).  The  external  nature  and  the  pre- 
liminary diagnosis  is  determined  upon  the  one  hand  by  the  great  softness  of 
the  tumor,  upon  the  other  by  the  dark  discoloration.  If  we  examine  it  micro- 
scopicalh',  we  tind,  besides  the  alveolar  structure,  which  appears  as  the  sum- 
mit of  development,  more  or  less  extended  parts,  which  bring  to  our  view 
former  stages  of  the  development  of  the  tumor.  The  most  common  is  an  infil- 
tration of  the  connective  tissue  with  pigmented  round  cells,  which  is  directly 
transformed  by  depot-like  accumulations  into  the  medullary  formation.  In 
other  cases  a  declared  sarcomatous  structure,  and  indeed  more  frequently 
the  spindle-celled  than  the  round-celled,  has  evidently  existed  for  some  time, 
ere  it  came  to  the  formation  of  the  characteristic  cell-balls.  Hence  we  are 
led  to  the  opinion  that  the  melanoses  in  general  are  closely  allied  to  each 
other,  a  view  which  we  will  follow  more  closely  upon  the  occasion  of  speak- 
ing of  the  commonly-called  pigmentary  sarcoma. 

^^  Spindle-celled  Sarcoma. — The  small-celled  spindle-celled  sarcoma  (s.  fuso- 
cellulare  durum)  occupies  the  same  position  among  the  spindle-celled  sarcomas 
that  the  granulation-like  sarcoma  does  among  the  round-celled  ones.  It 
deviates  the  least  from  the  model  of  inflammatory  new  formations,  because  it 
very  accurately  copies  after  that  spindle-celled  tissue  of  recent  cicatrices 
which  represents  the  regular  intermediate  degree  between  the  tissue  of  granu- 
lation and  the  tissue  of  cicatrices.  The  characteristic  textural  element  is  a 
short  and  narrow  spindle-cell  with  an  elongated  roundish  nucleus,  with  or 
without  nucleoli.  The  protoplasm  of  the  cell  is  finely  granular,  most  dense 
in  the  neighborhood  of  the  nucleus ;  a  limitary  membrane  is  nowhere  to  be 
perceived  with  certainty  ;  such  a  one  is  certainly  wanting  in  the  smaller  cells. 

"  In  the  mass  of  the  tumor,  the  spindle-cells  are  very  regularly  fitted 
together  in  such  manner  that  the  pointed  angle,  which  remains  between  the 
tapering  ends  of  two  elements  lying  side  by  side,  is  filled  out  by  the  tapering 
end  of  a  third,  which  is  respectively  situated  behind  and  before  them.  There 
is  nothing  to  be  seen  of  the  intermediate  substance ;  in  anj^  event  there  is  no 
more  present  than  a  tissue  of  granulation.;  but  this  minimum  quantity,  which 
properly  is  only  a  formless,  sticky  cell-cement,  must  also  not  be  Avanting  in 
the  spindle-celled  tissue.  By  its  aid  and  by  virtue  of  the  just-mentioned  har- 
monious arrangement  arise  lines  of  cells ;  there  are  formed  larger  and  smaller 
bundles,  which  furnish  the  next  higher  structural  element  of  the  spindle- 
celled  sarcoma.    Its  arrangement  in  the  rarest  cases  is  radiated,  so  that  united 

55 


882  ORAL  DISEASES  AND   SURGERY. 

rarely,  it  is  closely  set  on  the  surface  of  a  bone  confused  with  its 
periosteum."     The  sketches  of  fibrous  tumors  pictured  in  his  Sur- 

bundles  go  out  from  a  centrally  located  point ;  more  fi-equently  even  a  greater 
number  of  such  points  of  departure  are  given,  and  the  various  sj'stems  of 
bundles  interweave  in  the  various  directions  determined  by  the  location  of 
these  points  ;  generally,  however,  we  are  not  able  to  specify  any  positive  prin- 
ciple according  to  which  the  blending  of  the  bundles  into  a  whole  is  accom- 
plished, and  find  upon  every  transverse  section  bundles  which  are  divided 
longitudinally,  others  transversely,  and  yet  others  in  a  more  or  less  oblique 
directii)n.  The  determining  influence  for  the  course  of  the  cell-rows  has  been 
sought  in  the  course  of  the  vessels,  yet  incorrectly;  for  although  we  never 
fail  to  find  in  the  larger  fasciculi  of  the  tumor  a  larger  vessel  running  in  the 
same  direction,  yet  this  is  only  the  case  in  the  larger  fasciculi.  More  remotely 
the  vessels  break  up  entirely  relilbrm  as  in  other  parenchymas,  breaking 
through  the  cell-rows  in  all  imaginable  directions.  "Withal,  the  collective 
vessels,  even  the  larger  of  a  sarcoma,  have  almost  no  proper  walls,  and  pre- 
sent themselves  upon  transverse  sections  of  a  hardened  preparation  like  exca- 
vated canals  and  perforations. 

"  The  small-celled  spindle-celled  sarcoma  has  a  preference  for  the  connective- 
tissue  miMubranes,  fasciaa,  vascular  and  nervous  sheaths,  the  subcutaneous  and 
submucous  connective  tissues  ;  in  short,  it  has  the  same  seats  as  the  fibromas  ; 
it  is  also  often  enough  (for  example,  upon  the  uterus)  found  beside  fibromas. 
In  addition,  we  can  point  out  in  every  small-ceiled  spindle-celled  sarcoma 
such  places,  where  the  spindle-celled  tissue  is  transformed  into  fibrous  connect- 
ive tissue;  there  are  tumors  which  are  composed  half  of  the  one  and  half  of 
the  other,  so  that  a  relationship  close  to  an  identity  of  these  tumors  must  be 
accepted. 

"  The-  large-celled  npindte-celled  fiarcoma  is  anything  but  simply  a  varietj-  of 
the  small-celled.  The  important  ]ioint  in  which  it  is  distinguished  from  the 
latter  is  the  excessive  development  which  falls  to  the  lot  of  the  cells  in  oppo- 
sition to  all  the  other  constituents.  The  spindle  cells  may  attain  the  very 
respectable  thickness  of  0.015'''''',  and  so  enormous  a  length,  that  the  two  ends 
in  magnifying  by  200  diameters  are  separated  by  the  breadth  of  three  fields 
of  the  microscope.  The  cell  is  thickest  where  the  large,  elongated  roundish 
nucleus,  supplied  with  bright  nucleoli,  is  situated.  The  protoplasm  in  the 
neighborhood  of  the  nucleus  is  finely  granular  and  soft,  more  homogeneous 
towards  the  circumference  ;  a  cell-membrane  cannot  be  shown,  only  the  pro- 
cesses occasionally  show  so  considerable  a  firmness  and  so  strong  a  refractive 
power  that  they  must  be  regarded  as  protoplasm  having  become  rigid.  As 
to  the  number  of  processes  of  the  spindle-cell,  two  constitute  the  rule ;  three 
or  more  exceptionally  occur,  which  bestows  upon  the  cell  the  character  of  a 
stellate  cell.     (Virchow.) 

"  In  real  tj'pical  spindle-cellod  sarcomas,  these  cells  combine  into  larger 
strand-,  leaves,  and  fasciculi,  which  either  radiate  in  straight  lines  towards  all 
directions  from  a  common  basis  (radiary  sarcoma,  foliated  sarcoma),  or  they 
manifoldly  interweave  (trabecular  sarcoma).    These  tumors  may  attain  a  very 


TUMORS   OF  THE  MOUTH.  883 

gical  Pathology,  page  406,  might,  he  says,  be  repeated  for  myeloid 
tumors. 


considerable  circumference,  witliouta  farther  modification  of  their  texture  or 
structure  occurring.  The  enormous  growth  of  the  cells  occurs  in  a  certain 
measure  vicariousl_y  for  the  seasonable  development  of  fibrous  intercellular 
substance;  and  if  with  Max  Schultze  we  wish  to  see  in  the  latter  only  trans- 
formed protoplasm,  we  have  here  before  us  the  case  of  a  massively  produced, 
but  not  applied,  building-material. 

"  The  large-celled  spindle-eelled  sarcomas  proceed  from  fasciae  and  mem- 
branes, rarely  from  the  interstitial  tissues  of  glandular  organs.  They  are  of 
limited  malignancy,  and  are,  as  a  rule,  once  for  all  removed  by  a  seasonable 
extirpation.  Of  course  they  must  not  be  mistaken  for  radiating  cancers  and 
medullar}^  sarcomas. 

"  As  an  individual  variety  of  the  large-celled  spindle-celled  sarcoma,  there 
is  a  tumor  to  be  designated  which  is  observed  upon  the  skin  of  the  cheek, 
and  essentially  depends  upon  a  combination  of  the  round-celled  with  the 
spindle-celled  type.  Broad  fibrous  lines  of  spindle-shaped  cells  go  out  from 
one  or  more  points  ;  where  these  fibrous  lines  diverge,  the  round-celled  tissue 
fills  out  the  spaces. 

^^  The  piffmenfo,7-i/  sarco77ia  (s.  melanodes)  by  far  most  frequently  proceeds 
from  the  choroid  coat  of  the  eye,  then  from  the  outer  integument :  both  points 
at  which  normally  a  certain  pigmentary  infiltration  of  the  cellular  elements 
is  alread}'  observed.  We  comprehend  this  phenomenon,  as  a  rule,  in  such 
manner,  that  in  the  pathological  new  formation  a  vital  property  of  those  cells 
is  maintained,  from  which  this  proceeds.  Yet  precaution  is  to  be  recommended 
here.  The  metastatic  foci  of  tumors,  also,  which  are  not  rare  in  the  pro- 
nounced malignity  of  pigmentary  sarcoma,  show  the  same  disposition  to  pig- 
mentary infiltration,  although  they  develop  at  points  where  there  is  not  a  word 
to  be  said  of  physiological  pigmentation.  This  transfer  of  an  entirely  local 
peculiaritj'  to  the  secondary  tumors  has  been  used  as  well  for  as  against  this 
opinion:  for  it,  by  those  who  believe  that  the  metastasis  is  accomplished  by 
the  transfer  of  bodily  constituents  fi'om  the  primary  foci  of  development  to 
another  spot;  against  it,  by  those  who  believe  in  a  constitutional  disease- 
producing  tumor,  which,  wherever  it  produces  tumors,  produces  black  tumors. 

"  I  regard  it  as  imperative  in  this  case  to  keep  two  things  as  sharply  defined 
as  possible:  1,  the  incitation  of  metastasis  by  emigrant  cells  of  the  primary 
tumor  ;  and  2,  the  pigmentation  of  the  secondary  tumor.  As  to  1,  I  point  to 
the  suppositions  and  doubts  expressed  in  ^  120;  as  to  2,  we  must  constantly 
remember  that  all  the  cells  of  a  melanotic  tumor  are  colorless  in  their  youth. 
That  these  are  the  direct  offspring  of  the  emigrant  cells  of  the  primary  tumor, 
no  one  will  assert ;  they  are  rather  undoubtedly  local  products,  and  if  they  yet 
become  colored,  we  must  necessarily  refer  tliis  coloring  to  a  constitutional  dis- 
position, which  is  independent  of  the  location  of  the  primary  tumor.  With 
this  the  etiological  experiences  also  agree,  which  point  out  at  least  for  the 
outer  skin  asu})eifluous  formation  of  pigment  as  the  predisposing  cause.  This 
asserts  itself  either  in  the  production  of  black  warts,  which  may  directly 


884  ORAL  DISEASES  AND  SURGERY. 

These  two  kinds  of  tumors  are  described  as  being  equally  common 
to  the  jaws,  both  the  superior  and  inferior. 

degenerate  to  melanotic  sarcomas,  or  into  now  a  more  diffused,  now  a  more 
circumscribed,  brown  and  black  spotting  of  the  skin.  The  peculiar  predispo- 
sition of  creatures  not  at  all  pigmented,  as,  for  example,  the  white  horse,  to 
sarcoma  melanodes,  gives  more  the  impression  of  a  vicari(>us  deposition  of 
pigment,  accumulating  at  one  point,  and  therefore  combined  with  a  certain 
irritation  of  the  tissues. 

"  In  all  pigmentary  tumors  the  cells  are  the  exclusive  carriers  of  the  pig- 
ment. We  have  devoted  a  particular  consideration  to  the  histnlogical  detail 
of  pigmentary  infiltration.  ^I  referred  for  the  case  of  pigmented  tumors  the 
opinion  of  a  pigmentary  formation,  derived  only  from  hemorrhages,  and  for 
this  presented  the  view  that  the  question  here  is  about  the  taking  up  of  the 
coloring-matter  of  the  blood  from  the  blood.  "What  inclines  me  by  prefer- 
ence to  this  assertion,  leaving  out  of  consideration  the  deficient  proof  of  a 
hemorrhagic  production,  is  an  observation  uj)on  the  first  origin  of  pigment  in 
such  tumors  as  had  existed  for  some  time  as  simple  medullary  sarcomas,  then 
to  be  transformed  into  melanotic  tumors,  and  as  such  to  form  their  recurrences 
and  metastases.  We  can  here  not  infrequently  convince  ourselves  that  the 
first  traces  of  pigmentary  infiltration  were  visible  at  the  epithelia  of  the 
vessels.  Can  this  be  interpreted  otherwise  than  that  the  epithelia  have  taken 
up  the  diffused  coloring-matter  from  the  blood?  that  it  has  been  condensed  in 
them  and  precipitated  in  granular  form  ?  And  when  afterwards  entirely  the 
same  formation  of  pigment  shows  itself  beside  the  vessels,  when  finally  it 
occurs  in  the  whole  parenchyma  of  the  tumor,  according  to  my  judgment 
we  may  not  doubt  that  it  is  also  accomplished  here  in  the  same  manner  as 
upon  the  epithelia  of  the  vessels,  by  taking  up  the  diffuse  coloring-matter  from 
the  blood. 

"In  view  of  the  discussed  general  pathological  relations  of  melanotic 
tumors,  their  anatomical  position  falls  more  into  the  background.  That 
which  is  commonly  called  pigmentary  cancer  has  been  already  described 
as  round-celled  alveolar  or  medullary  pigmentary  sarcoma.  The  remaining 
pigmentary  tumors,  as  a  rule,  belong  to  the  spindle-celled  sarcomas.  These 
are  generally  of  more  compact  consistency,  and  of  foliated  or  fasciculated 
arrangement.  In  the  decided  tendency  to  form  superficial  elevations,  tuber- 
osities, and  fungi,  which  otherwise  is  also  peculiar  to  round-celled  sarcoma, 
a  contrast  to  be  well  noticed  is  expressed  against  destructive  carcinomas.  In 
regard  to  color,  the  above-mentioned  principle  is  the  measure  of  the  pigment- 
less  youthful  state  of  the.  constituent  elements.  There  are  pigmentary  sar- 
comas of  considerable  size,  which  first  of  all  only  betray  their  true  character 
by  a  black  and  brown  striation,  a  spotted  or  dappled  appearance.  The  deep 
brownish-black  sepia  color  only  represents  the  highest  degree  of  pigmentary 
infiltration. 

"A  fibromatous  constitution,  according  to  Yirchow,  only  pertains  to  the 
above-mentioned  black  fungosities  of  the  white  horse,  which  also  distinguish 


TUMORS  OF  THE  MOUTH.  885 

"When  the  myeloid  is  inclosed  in  bone,  the  tumors  usually  tend 
to  the  ovoid  or  spherical  shape,  and  are  well  defined,  if  not  invested 

themselves  by  th(3ir  benignity  essentially  from  all  other  constantly  malignant 
melano-sarcomas. 

"  Fibrous  Sarcoma.  —  The  fibroids.  I  cannot  separate  the  fibroma  from  the 
sarcomas.  With  the  same  correctness  with  which  we  sought  the  paradigm 
of  round- and  spindle-celled  sarcomas  in  the  round- and  spindle-celled  tissues 
of  the  inflammatory  new  formation,  will  we  seek  and  find  the  model  of  fibro- 
matous  texture  in  the  completed  cicatricial  tissue. 

"  The  common  fibroid  (desmoid)  consists  of  a  fibrous,  reddish-white,  tightly 
elastic,  and  so  dense,  compact,  even  hard  tumor,  that  in  cutting  it  it  creaks 
under  the  knife.  The  textural  elements  are  those  of  cicatricial  tissue.  If  we 
tear  oflF  a  minute  fibril  from  the  cut  surface  and  pull  it  to  pieces,  we  are  aston- 
ished at  the  enormous  volume  which  the  fibril  assumes,  that  is  to  say,  the 
enormous  number  of  more  minute  flbrilla3  into  which  it  may  be  broken  up. 
The  microscope,  however,  tells  us  that  each  of  these  smaller  fibrils  is  also 
yet  a  complication  of  very  delicate,  minutest  fibrils,  only  marked  by  a  single 
but  sharply-defined  line.  Like  as  a  well-braided  tress  occupies  far  less  space 
than  a  dishevelled  braid  of  hair,  although  both  contain  the  same  amount  of 
hair,  so  we  must  also  here  represent  to  ourselves  that  in  the  fibroma  the  fine 
and  the  finest  fibrils  are  extraordinarily  closely  pressed  together,  until  they 
are  loosened  by  our  needles,  and  then  occupy  an  astonishing  amount  of  space. 

"  Between  the  fibrils,  which  are  formed  of  glue-yielding  substance,  and 
have  the  significance  of  a  fibrous  intercellular  substance,  the  cells  are  visible  ; 
as  a  rule,  small,  oval  structures,  with  shining  nuclei.  Virchow  has  been 
induced,  by  the  great  similarity  of  these  with  smooth  muscular  fibre,  to  set 
up  a  fibro-muscular  tumor  as  a  particular  variety  of  fibroma.  I  am  very  far 
from  wishing  to  bring  this  resemblance  into  question ;  a  determination  of 
the  histological  boundary  between  spindle-cells  and  smooth  muscular  fibres  is 
in  fact  a  very  precarious  thing;  meanwhile,  I  regard  it  as  conformable  to 
continue  for  the  present  the  comparison  of  sarcoma  with  the  inflammatory 
new  formation,  the  sarcoma-spindles  with  the  cicatricial  spindles.  By  this 
we  obtain  a  useful  foundation  for  understanding  the  collective  structural 
elements  occurring  in  fibroids;  for  what  has  been  hitherto  described  only 
constitutes  the  principal  mass  of  the  tumor  ;  besides  which  we  find,  1,  rows  of 
spindle-cells,  which  run  through  the  tumor  in  various  directions ;  2,  round- 
ish foci  of  germinal  tissue,  which  are  here  and  there  sprinkled  into  the  con- 
tinuity of  the  fibres.  I  regard  both  as  transition  formations,  from  which  the 
fibrous  tissue  is  developed  in  entirely  the  same  way  as  the  cicatrix  from  the 
germinal  and  spindle-celled  tissues.  I  found  numerous  fibromas  upon  a  uterus, 
of  which  the  larger  principally  consisted  of  fibrous  tissue,  the  smaller  ones 
almost  only  of  spindle-celled  tissue. 

"  The  cut  surface  of  the  tumor  deserves  an  especial  consideration.  The 
intimate  inteiHwining  and  interweaving  of  the  fibrous  lines  bestows  upon  it  a 
peculiar  impress.  Microscopic  examination  particularizes  the  appearance 
which  the  naked  eye  perceives,  without  acquainting  us  with  the  cause  of  the 


886  ORAL  DISEASES  AND  SURGERY. 

with  distinct  thin  capsules ;  seated  on  bone,  they  are  much  less  de- 
fined, less  regular  in  shape,  and  often  deeply  lobed.  They  feel  like 
uniformly  compact  masses,  but  are  in  different  instances. variously 
consistent.  The  most  characteristic  examples  are  firm,  and  (if  by 
the  name  we  may  imply  such  a  character  as  that  of  the  muscular 
substance  of  a  mammalian  heart)  they  maybe  called  fleshy.  Others 
are  softer,  in  several  gradations,  to  the  softness  of  size  gelatin,  or  to 
that  of  a  section  of  granulations.  Even  the  firmer  are  brittle,  easily 
crushed  or  broken;  they  are  not  tough,  nor  very  elastic,  like  the 
ordinary  fibro-cellular  or  fibrous  tumors,  neither  are  they  grumous 
or  pulpy,  neither  do  they  show  a  fibrous  or  granular  structure  on 
'their  cut  or  broken  surfaces;  these  tumors  are  smooth,  uniform, 
compact,  shining,  succulent,  with  a  yellowish,  not  a  creamy  fluid. 
A  peculiar  appearance  is  given  commonly  to  them  by  the  cut  surface 
presenting  blotches  of  dark  or  livid  crimson,  or  of  a  brownish  or  a 
brighter  blood  color,  or  of  a  pale  pink,  or  of  all  these  tints  mingled 
on  the  grayish-white  or  greenish  basis-color.  [In  a  foot-note,  Mr. 
Paget  quotes  from  Lebert,  who  says  the  greenish-yellow  color  that 
may  show  depends  on  a  peculiar  fat,  xauthose.]  The  tumors  may 
all  be  pale,  or  have  only  few  points  of  ruddy  blotching,  or  the  cut 

arrangement.  For  the  arrangement  of  the  mass  of  some  tibromas  the  cir- 
cumstance appears  of  imj)ortance,  that  the  new  formation  particularly  local- 
izes itself  upon  the  vessels  and  nerves  of  a  part.  Thus  Billroth  has  described 
a  fibroid  of  the  eyelids,  and  given  it  to  me  for  subsequent  investigation, 
which  consists  of  numerous  sausage-like  cylinders,  in  whose  axes  the  remains 
of  small  nerve-trunks  are  distinctly  visible.  Based  upon  this,  Czerny  has 
lateh'  separated  a  particular  group  of  sarcomas  as  '  plexiform  tumors,'  be- 
cause beside  the  nerve-branches  he  also  proclaimed  the  ramification  of  the 
vessels  as  the  occasional  cause  of  these  striking  structural  relations.  It  must 
be  marked  as  the  most  striking  formation  belonging  to  this  class,  when  the 
collective  vessels  of  a  tumor,  in  itself  myxomatous,  are  surrounded  by  a  rela- 
tively thick  sheath,  upon  which  we  can  throughout  recognize  a  round-celled 
nature.  An  influence  of  the  course  of  the  vessels  upon  the  course  of  the 
fibrous  bundles  cannot  be  established  in  ordinary  fibromas.  The  view  is 
much  more  probable  to  me,  that  in  the  peculiarly  central  growth  of  the 
fibroma  the  new  tumor-mass  is  inserted  between  the  existing  fibrous  rows, 
pressing  tliem  asunder,  and  thus  the  incomplete  stratified  structure  of  the 
tumor  is  conditioned  by  repeated  separation  of  these  fibres,  and  not  by 
superjjosition. 

"  Fibroma  correctly  ranks  as  one  of  the  benign  new  formations.  We  will 
learn  to  know  the  uterus  as  its  preferred  scat,  and  at  the  same  time  a  series 
of  interesting  modifications  of  the  anatomical  appearance  just  sketched." — 

KiNDFLEISCH, 


TUMORS  OF  THE  MOUTH.  887 

surface  may  be  nearly  all  suffused,  or  even  the  whole  suljstance  may 
have  a  dull  inodena  or  crimson  tinge,  like  the  ruddy  color  of  a  heart, 
or  that  of  the  parenchyma  of  a  spleen.  Many  of  what  have  been 
named  spleen-like  tumors  of  the  jaws  are  of  this  kind.  The  color 
they  present  is  not  due  merely  to  blood  in  them;  some  of  it  is  ap- 
propriate to  their  texture,  as  is  that  of  the  spleen  or  that  of  granu- 
lations, and  it  may  be  quickly  and  completely  bleached  with  alcohol." 
Tlie  following  are  the  microscopic  appearances  pronounced  pecu- 
liar to  the  myeloid  growth,  being  imitated  in  no  other  morbid 
structure  : 

1.  Cells  of  oval,  lanceolate,  or  angular  shape,  or  elongated  and 
attenuated  like  fibre-cells,  or  caudate  cells,  having  dimly-dotted  con- 
tents, with  a  single  nucleus  and  nucleolus. 

2.  Free  nuclei,  such  as  may  have  escaped  from  the  cells,  and, 
among  these,  some  that  appear  enlarged  and  elliptical,  or  variously 
angular,  or  are  elongated  toward  the  same  shapes  as  the  lanceolate 
and  caudate  cells,  and  seem  as  if  they  were  assuming  the  character 
of  cells. 

3.  The  mo.st  peculiar  form  :  large,  round,  oval,  or  flask-shaped,  or 
irregular  cells  or  cell-like  masses,  or  thin  disks  of  clear  or  diml}^- 
granular  substance,  measuring  from  one  three-hundredths  to  one- 
thousandth  of  an  inch  in  diameter,  and  containing  two  to  ten  or 
more  oval,  clear,  and  nucleolated  nuclei. 

Corpuscles  such  as  these,  irregularly  and  in  diverse  proportions 
imbedded  in  a  dimly-granular  substance,  make  up  the  mass  of  a 
myeloid  tumor.  They  may  be  mingled  with  molecular  matter,  or 
the  mass  they  compose  may  be  traversed  with  filaments  or  with 
bundles  of  fibro-cellular  tissue  and  blood-vessels,  but  their  essential 
features  (and  especially  those  of  the  many-nucleated  corpuscles)  are 
rarely  observed. 

Many  varieties  of  aspect  (as  remarked  by  Mr.  Paget)  may  thus 
be  observed  in  myeloid  tumors,  and  beyond  these  they  may  even  be 
so  changed  that  the  microscope  may  be  essential  to  their  diagnosis. 
After  they  partially  ossify,  well-formed  cancellous  bone  being  de- 
veloped in  them,  cysts,  also  filled  with  bloody  or  serous  fluids,  may 
be  formed  in  them,  occupying  much  of  their  volume,  or  even  almost 
excluding  the  solid  texture. 

This  author  notes  a  case  in  which  he  lately  amputated  the  leg  of 
a  woman,  twenty-four  years  old,  for  what  was  supposed  to  be  a 
cancerous  tumor  growing  within  the  head  of  the  tibia.  She  had  had 
pain  in  the  part  for  eighteen  months,  and  increasing  swelling  for  ten 


888  ORAL  DISEASES  AND  SURGERY. 

months,  and  it  was  plain  that  the  bone  was  expanded  and  wasted 
around  some  soft  growth  within. 

On  section,  after  removal,  the  head  of  the  tibia,  including  its  ar- 
ticular face,  appeared  expanded  into  a  rounded  cyst  or  sac  about 
three  and  a  half  inches  in  diameter,  the  walls  of  which  were  formed 
by  this  flexible  bone  and  periosteum,  and  by  the  articular  cartilages 
above;  within  there  was  little  more  than  a  few  bands  or  columns 
of  bone,  among  a  disorderly  collection  of  c^'sts  filled  with  blood,  or 
blood-colored  serous  fluids.  The  walls  of  most  of  the  cysts  were 
thin  and  pellucid;  those  of  others  were  thicker,  soft,  and  brownish- 
yellow,  like  the  substance  of  some  medullary  cancers,  a  likeness  to 
which  was  yet  more  marked  in  a  small  solid  portion  of  tumor, 
which,  though  very  firm,  and  looking  fibrous,  was  pure  white  and 
brain-like. 

No  one,  Mr.  Paget  says,  who  examined  this  disease  with  the  naked 
eye  alone,  felt  any  doubt  that  it  was  an  example  of  medullary  cancer, 
with  cysts  abundantly  formed  in  it.  But,  on  minute  investigation, 
none  but  the  elements  of  the  myeloid  tumors  could  be  found  in  it; 
these,  copiously  imbedded  in  a  dimly-granular  substance,  appeared 
to  form  the  substance  of  the  cyst-walls,  and  of  whatever  solid  ma- 
terial existed  between  them.  The  white  brain-like  mass  was  appa- 
rently composed  of  similar  elements  in  a  state  of  advanced  fatty 
degeneration,  but  neither  in  it  nor  in  any  other  part  could  be  found 
a  semblance  of  cancer-cell. 

No  mention  is  made  of  the  return  of  the  disease;  it  would  seem 
that,  in  the  present  state  of  our  knowledge  of  cancer-growths,  it 
would  have  been  a  very  difficult  matter  to  class  such  a  tumor  with 
the  non-malignant.  It  certainly  was  very  heteroclitic  in  character, 
and  whatever  we  individually  may  feel  disposed  to  think  of  such  a 
structure,  it  serves  to  exhibit  the  merging  of  the  commonly  deemed 
benign  into  the  malignant,  and  the  relationship  of  the  two.  A  con- 
sideration of  such  cases  as  this  should  serve  to  keep  the  practitioner 
on  his  guard,  preventing  his  being  too  confident  in  any  prognosis 
he  may  give  to  a  patient. 

An  epitome  of  the  myeloid  may  thus  be  presented  : 

They  are  a  class  of  fleshy  tumors  called  by  M.  Lebert  fibro-plastic, 
because,  he  says,  they  are  made  up  of  fibre-cells.  They  are  called 
myeloid  by  Mr.  Paget,  because  he  thinks  they  I'esemble  marrow 
much  more  than  fibrous  tissue. 

In  character,  "they  vary  from  simple  semi-fibrous,  semi-marrow- 


TUMORS   OF   THE  MOUTH.  889 

like  structures  to  those  so  heteroclitic  that  they  seem  to  merge  into 
the  medullary." 

Their  favorite  seat  seems  to  be  about  the  bones,  either  intra  or 
extra,  being  perhaps  more  common  in  the  maxillae  than  in  any  other 
osseous  structures. 

They  are  growths  which  usually  occur  singly;  they  are  more  fre- 
quent in  youth,  and  very  rare  after  middle  age  ;  they  generally  grow 
slowly  and  without  pain,  and  usually  commence  without  any  known 
cause,  such  as  injury  or  hereditary  disposition. 

According  to  Mr.  Paget,  they  rarely,  except  in  portions,  become 
osseous  ;  they  have  no  proneness  to  ulcerate  or  protrude  ;  they  seem 
to  bear  even  considerable  injury  without  becoming  exuberant ;  they 
may  shrink  or  cease  to  grow  ;  they  are  not  apt  to  recur  after  com- 
plete removal,  nor  have  they  in  general  any  features  of  malignant 
disease. 

Since  writing  the  above  the  author  has  accidentally  fallen  upon 
a  classification  of  the  tumors  of  the  upper  jaw,  made  by  Mr.  Hancock. 
After  alluding  to  various  classes,  he  says,  "In  addition  to  these, 
Mr.  Paget  adds  what  he  terms  myeloid  tumors  of  the  part ;  but  while 
the  examples  he  quote  resemble  on  the  one  hand  so  much  the  fibrous, 
on  the  other  the  medullary  tumors,  their  true  character,  whether 
innocent  or  malignant,  is  so  very  doubtful  that  I  should  hesitate  in 
admitting  them  as  a  distinct  class." 

Epitome. — Fibrous  tumors  proper,  and  the  fibro-plastic,  have 
general  features  in  common, — that  is,  they  belong  to  the  class  of 
sarcomatous  growth  ;  but  then  in  a  pathological  sense  they  have  such 
differences  that  an  epitome,  at  least,  oftheir  history  should  be  reviewed 
by  us. 

In  some  instances,  fibrous  tumors  are  seen  under  the  microscope 
to  have  a  concentric  development:  this  species  is  slowest  of  growth, 
is  most  benign,  and  never  attains  any  great  size. 

In  another  species  the  fibres  interlace  in  a  most  complicated  and 
irregular  manner.  This  kind  attains  the  largest  size,  and  seems 
striding  toward  the  heteroclitic. 

A  third  class  consists  of  an  aggregate  of  nodules,  and  is  compared 
by  Dr.  Humphrey  to  a  conglomerate  gland;  the  tumor  being  made 
up  of  small  masses  closely  compressed  together,  having  an  uneven, 
knotty  outline. 

Fibrous  tumors  affecting  the  bones  (Braithwaite)  are  usually  found 
upon  those  of  a  spongy  nature,  upon  the  ends  of  the  long  bones,  the 
phalanges,  pelvis,  and  in  the  jaws.  "  So  far,"  says  this  author,  "  as  I 


890  ORAL  DISEASES  AND  SURGERY. 

have  met  with  them,  they  are  confined  to  the  exterior  of  the  lower 
jaw,  growing  from  the  periosteum  and  creeping  along  the  surface  of 
the  bone  in  such  a  manner  as  to  prove  almost  to  a  certainty  that 
they  originate  in  some  morbid  condition  of  the  periosteal  fibres.  The 
bone  underneath  these  tumors  may  suffer  absorption  in  consequence 
of  the  pressure  i)roduced,  but  does  not  seem  to  be  affected  in  any 
other  way.  They  appear  upon  the  maxillary  bone  more  frequently 
than  upon  any  other  part  of  the  skeleton.  On  the  lower  jaw  they 
spread  along  the  ramus,  encircling  it  beneath  and  on  the  sides,  so 
that  the  bone  is  almost  concealed  by  the  tumor.  In  some  instances 
they  form  within  the  substance  of  the  jaw,  probably  from  the  alveolo- 
dental  membrane,  and  as  they  increase,  the  walls  of  the  bone  become 
spread  out  over  them.  They  grow  up  around  the  teeth,  and  when 
they  project  into  the  mouth  may  be  soft  aiul  fungous."* 

In  some  instances  the  fibrous  tumors  of  the  jaws  exhibit  a  semi- 
cartilaginous  structure,  and  now  and  then  fibres  or  plates  of  bone 
are  formed  in  various  parts  of  them.  The  progress  of  the  disease 
is  well  illustrated  by  a  series  of  tumors  of  the  jaws  in  the  College 
of  Surgeons,  London,  from  the  museum  of  the  late  Mr.  Liston, 
These  preparations  serve  to  show  how  necessary  it  is  to  bear  in 
mind  the  mode  of  growth  of  these  periosteal  fibrous  tumors  of  the 
jaws,  because  from  their  disposition  to  creep  along  the  surface  of 
the  bone,  whether  it  be  an  endosteum  or  periosteum,  they  are  liable 
to  return  after  removal,  unless  the  immediately  adjacent  as  well  as 
afifected  parts  be  excised.  The  histories  attached  to  the  specimens 
teach  that  very  large  fibrous  tumors,  both  of  the  upper  and  lower 
jaws,  together  with  the  bones  on  which,  or  in  which,  they  grow,  may 
be  successfully  removed. 

Cysto-savcoma,  an  expression  as  implied  by  the  prefix,  is  a  tumor 
of  only  semi-solidity,  its  interior,  or  stroma,  l^eing  made  up  of  cysts 
and  fleshy  substance.  These  cysts  are  original  formations,  and  not 
of  secondary  character, — that  is,  they  are  not  the  result  of  molecular 
disintegration.  They  are  lined  sacs,  having  a  distinct  secretory 
membrane.  Miller  describes  the  contents  of  these  cysts  as  widely 
differing,  and  which  every  one  must  have  observed  :  "  They  are  more 
or  less  fluid,  sonietimesa  clear  gluey  liquid,  sometimes  a  gelatinous, 
pale  mass  of  semi-solid  consistence,  elastic,  and  projecting  beyond 

*  Presenting  this  phase,  the  tumor  may  be  classed  with  the  epulic,  but  it 
will  be  seen  that  on  this  account  there  need  be  no  confusion.  Many  epulic 
tumors  are  osteo-sarcomatous. 


TUMOBS  OF  THE  MOUTH.  891 

the  level  of  the  cut  cyst  on  a  section  being  made  ;  sometimes  a  solid, 
consisting  of  a  fibrous  deposit,  organized  very  imperfectly,  if  at  all ; 
sometimes  of  an  exanthematous  or  poppy  consistence,  as  in  many 
encysted  tumors ;  sometimes,  but  more  rarely,  a  dark  fluid,  like 
printers'  ink,  is  contained;  sometimes  blood  is  mingled  with  the 
contents,  either  in  the  solid  or  in  the  coagulated  form." 

The  very  nearest  approach,  however,  made  by  cysto-sarcoma  to 
the  explainable  cysts,  is  in  that  class,  very  well  named  by  some  one, 
as  I  remember  to  have  seen,  the  "  cysto-succulent."  These  are  sar- 
comatous tumors,  the  stroma  of  which  is  made  up  of  very  loose 
fibro-cellular  tissue.  They  might  well,  in  their  contents,  be  likened 
to  a  watermelon,  solid  enough  on  section,  but  compressible  to  a 
few  shreds.  The  fibrous  contents  of  the  stroma  are,  however, 
always  a  distinguishing  sign.  These  tumors  are  very  rare,  and 
particularly  so  about  the  bony  structures. 

Midler  has  described  a  variety  of  these  cysts  of  sarcomatous 
growth,  which  he  calls  cysto-sarcoma  phyllodes.  "  The  tumor,"  be 
says,  "  forms  a  large  firm  mass,  with  a  more  or  less  uneven  surface. 
The  fil)rous  substance,  which  constitutes  a  greater  part  of  it,  is  of  a 
grayish-white  color,  extremely  hard,  and  as  firm  as  fibro-cartilage. 
Large  portions  of  the  tumor  are  made  up  entirely  of  this  mass,  but 
in  some  parts  are  cavities  or  clefts,  not  lined  with  a  distinct  mem- 
brane (an  exception  to  the  rule  in  cystic  tumors).  These  cavities 
contain  but  little  fluid,  for  either  their  parietes,  which  are  hard,  like 
fibro-cartilage,  and  finely  polished,  lie  in  close  apposition  with  each 
other,  or  a  number  of  firm,  irregular  laminae  sprout  from  the  mass 
and  from  the  walls  of  the  fissures,  or  excrescences  of  foliated  or  wart- 
like form  sprout  from  the  bottom  of  the  cavities  and  fill  up  the  in- 
terior. These  excrescences  are  perfectly  smooth  on  their  surfaces, 
and  never  contain  cysts  or  cells.  The  lamina  lie  very  irregularly, 
and  project  into  the  cavities  and  fissures  like  the  folds  of  the  psal- 
teriuin  in  the  interior  of  the  third  stomach  of  ruminant  animals. 
Sometimes  the  laminae  are  but  small,  and  the  warty  excrescences 
from  the  cysts  are  very  large,  while  in  other  instances  both  are 
greatly  developed." 

Cartilaginous,  or  the  enchondromatous  tumors  of  Miiller,  niig-ht, 
perhaps,  for  all  practical  purposes,  be  classified  with  the  sarcojnatous, 
for  while  it  might  demand  some  little  stretch  of  the  imagination  to 
convert  a  cartilage  into  looking  like  a  fleshy  mass,  yet  surgically  the 
species  are  very  much  alike, — that  is,  both  are  reasonably  benign, 


892  ORAL  DISEASES  AND   SURGERY. 

both  are  little  amenable  to  the  action  of  the  sorbefacients,  and  both 
are  better  treated  by  the  knife  than  in  any  other  way. 

As  we  understand  the  osteo-sarcoraatous  tumors  proper  to  be  out- 
growths associated  commonly  with  periosteal  membranes,  so  we  are 
led  naturally  to  ask  ourselves  as  to  the  cause  of  their  formation. 
This  may  be  conceived  to  be  twofold  :  first,  as  the  result  of  local 
irritation;  second,  as  the  result  of  constitutional  conditions;  and, 
still  again,  we  may  combine  these  two,  laying  the  predisposing  cause 
on  the  one  and  the  e.xciting  on  the  other. 

The  attention  of  the  author  was  once  directed  by  William  Gibson, 
late  Professor  of  Surgery  in  the  University  of  Pennsylvania,  to  a 
case  markedly  illustrative  of  this  latter  condition.  An  old  gentleman, 
Mr.  F.,  seventy  years  of  age,  was  struck  on  the  cheek  by  a  stone. 
He  soon  had  growing  from  the  site  of  the  injury  a  tumor,  diagnosed 
by  Professor  G.  as  osteo-sarcomatous.  The  growth  of  the  body  was 
so  rapid  and  so  formidable  as  to  incline  to  the  view  of  its  intimate 
relationship  with  malignancy.  No  one  would  doubt  the  twofold 
relation  of  such  a  tumor. 

When  osteo-sarcoma  takes  on  this  rapid  growth,  its  innocency 
may  always  be  doubted  ;  when  the  development  is  slow  and  regular, 
and  particularly  if  the  origin  can  be  traced  to  some  local  irritant, 
extirpation  may  be  expected  to  result  in  a  cure.  » 

Osteo,  or  simple  sarcomatous  tumors  of  the  sinus  maxillare,  should 
not  be  mistaken,  as  has  too  often  been  the  case,  for  polypi  of  the 
nares.  It  sometimes  happens  that  these  tumors,  particularly  the 
softer  kinds,  find  their  way  through  the  outlet  of  the  sinus  into  the 
nostril,  and  there  simulate  very  closely  a  common  fibrous  poh'pus ; 
such  tumors  have  been  often  highly  aggravated  by  operations  founded 
on  such  mistaken  diagnosis.  Again,  poh'-pi  of  the  nostrils  may  find 
their  way  through  the  same  passage  into  the  sinus,  and,  enlarging, 
represent  very  fairly  the  ordinary  sarcomatous  tumor  of  that  cavity. 
Now,  pathologically  speaking,  being  about  one  and  the  same  thing, 
it  would  be  little  difference  where  or  how  the  growth  should  develop, 
but  as  operative  proceedings  are  concerned,  a  mistake  of  the  kind 
becomes  quite  an  awkward  matter. 

As  regards  changes  common  to  the  sarcomatous  tumors,  they 
may  be  considered  under  the  heads  of  softening,  suppuration,  and 
malignant  degeneration. 

Softening,  as  inferred  by  Dr.  Humphrey,  appears  to  take  place  in 
two  ways  : 

First,  as  a  chronic  process,  affecting  some  circumscribed  portion 


TUMORS   OF   THE  MOUTH.  893 

of  the  tumor,  M'liich  is  usually  at  or  near  the  centre.  The  change 
is  observed  to  commence  with  a  slight  discoloration,  a  yellowish  or 
dark  tinge,  which  is  followed  by  a  loosening  or  incipient  disintegra- 
tion of  the  structure  ;  at  the  same  time  a  line  of  demarkatioii  is  formed 
around  the  altered  portion,  which  becomes  separated,  like  a  seques- 
trum, from  the  surrounding  mass.  Both  the  detached  portion  and 
the  cavity  are  at  first  rough  and  thready  on  their  opposed  surface; 
the  former  undergoes  still  further  disintegration  and  solution,  be- 
coming broken  up  into  a  number  of  smaller  fragments,  which  float 
about  in  a  dark,  dirty,  turbid  fluid,  and  which  may  ultimately  dis- 
appear. 

The  process  of  destruction  may  go  on  in  the  adjacent  portion  of 
the  tumor,  enlarging  the  central  cavity  till  the  whole  is  reduced  to 
a  fluid  or  a  semi-fluid  mass,  walled  in  by  the  capsule  of  the  tumor, 
which  now  stands  in  the  relation  of  a  cyst-wall  to  the  disorganized 
contents. 

In  some  cases  the  softening  process  is  completed  without  extend- 
ing the  circumference  ;  the  ragged  processes  hanging  into  the  interior 
of  the  cavity  are  removed.  The  latter  acquire  a  smooth  lining,  and 
look  like  a  simple  cyst  lying  in  the  cavity  of  the  tumor. 

A  second  mode  in  which  softening  takes  place  is  more  rapid  and 
diffused,  the  whole  or  the  greater  portion  of  the  tumor  being  affected 
at  once.  The  change  commences  with  the  infiltration  into  the  mass 
of  a  serous  fluid,  whereby  its  texture  is  loosened  and  its  components 
separated  ;  at  the  same  time  the  tissue  of  the  tumor  is  softened,  and 
interstitial  absorption  is  set  up  in  it. 

As  the  result  of  these  processes  combined,  the  tumor  is  soon 
broken  up  into  detached  fragnients,  and  reduced  to  a  diffluent  pulp, 
or  it  may  be  completely  liquefied.  These  changes,  Dr.  Humphrey 
suggests,  "  are  occasioned  by  some  altered  nutrition  analogous  to 
inflammation;  they  may  be  induced  by  some  accidental  cause,  as  an 
injury;  nevertheless  they  are  not  necessarily  attended  with  any 
constitutional  disturbance  at  all  corresponding  with  the  extensive 
destruction  which  is  in  progress." 

Sirpiniralion. — This  is  very  rare ;  it  may  commence  internally,  or 
progress  from  without  inward. 

Cancerous  Degeneration  — The  general  conditions  and  features 
of  such  degenerations  will  find  consideration  in  the  succeeding  chap- 
ter. Just  here,  however,  a  second  cancerous  relation  may  be  alluded 
to,  namely,  the  existence  of  compound  tumors.  Dr.  Lewis  relates  a 
case  where  melanotic  cancer  was  deposited  in  the  stroma  of  a  fibrous 


894 


ORAL  DISEASES  AND  SURGERY. 


tumor,  and  Dr.  Humphrey  describes  a  large  fibrous  tumor  completely- 
enveloped  in  cancer. 


Fig.  274. — Osteo-Sarco- 
MATOus  Tdmor. 


Tig.  275. — Cysto-Sarcoma. 


The  tumor  represented  in  Fig.  274,  from  the  person  of  an  old 
woman,  commenced  within  the  antrum,  and  progressed  four  years 
before  causing  death.  In  character  it  was  fibro-plastic,  with  here 
and  there  osseous  masses. 

Fig.  275  represents  a  cysto-sarcoma.  It  is  a  section  of  the  dis- 
eased lower  jaw  of  a  man  aged  about  thirty.  Death  occurred  within 
a  year,  from  return  of  the  disease. 


CHAPTER    XLIII. 

THE    TUiMORS   OF   THE    MOUTH. 

THE   NON-EXPLAIXABLE   TUMORS. 

Here  again,  did  we  know  where  benignancy  ends  and  where 
malignancy  begins,  our  chapter  might  have  a  different  heading;  but, 
knowing  that  expressions  of  the  fibromata  will  as  surely  progress  to 
the  destruction  of  a  patient  as  any  epithelial  foundationed  tumor 
which  histology  describes,  it  is  impossible  to  do  otherwise  than 
place  all  such  tumors  under  a  common  head. 

For  convenience,  however,  we  continue  the  study  of  the  remaining 
tumors  under  the  familiar  term  carcinoma,  yet  meaning  by  it  nothing 
different  from  an  expression  of  the  vice  cancer. 

Carcinoma,  as  the  term  has  become  identified  with  clinical  im- 
pressions, would  seem  to  be  a  condition  isolated  entirely  from  such 
as  we  have  studied,  inasmuch  as  it  is  a  disease  considered  to  be 
of  a  peculiarly  malignant  and  rapid  character;  such  differences, 
however,  find  explanation,  as  has  been  remarked  in  the  preliminary 
pages,  in  the  circumstances  of  the  individual,  and  in  the  character 
of  the  disease  itself. 

Carcinoma,  according  to  the  classification  of  Fische,  which,  as  well 
as  any  other,  we  may  adopt,  is  a  word  derived  from  the  Greek  Aapxi- 
voi;,  signifying  a  "crab;"  it  applies  to  a  family  of  expressions  which 
embrace  the  different  forms  of  what,  by  the  usual  classification,  is 
recognized  as  cancer. 

Primarily,  if  a  real  difference  exists  between  a  cancer  proper  and 
the  conditions  just  considered,  there  should  exist  a  distinctive  some- 
thing to  typify  it*    Does  this  something  appear  ?    In  the  foot-notes 

*  "  The  exposition  of  genenil  points  of  view  concerning  the  nature,  the 
origin,  and  the  relationship  of  the  so-called  '  carcinoma,^  will  form  the  chief 
contents  of  this  section.  By  '  carcinoma'  we  understand  a  new  lormation 
destroying  the  organs  of  the  body,  after  extirpation  commonly  recurring 
and  undergoing  metastasis,  therefore  malignant.    These  projicrties  certainly 

(  895  ) 


896  ORAL  DISEASES  AND   SURGERY. 

from  Ilindfleisch  and  Billroth,  the  subject  is  discussed  ;  let  the  reader 
acquaint  himself  with  these  latest  teachings  of  two  of  the  most 

pertain,  as  we  have  seen,  also  to  certain  histoid  tumors;  and  it  were  exceed- 
inglj'  desirable,  if  there  were  a  positive  anatomical  cliaracteristic  by  which 
we  could  recognize  carcinoma  as  such,  and  could  distinguish  it  from  other 
destructive  and  malignant  new  formations.  We  have  now  become  accus- 
tomed, and  to-day  we  yet  hold  fast  this  custom,  of  regarding  a  certain  peculi- 
arity of  structure,  the  so-called  alveolar  structure,  as  a  necessary  requisite 
for  tlie  diagnosis — cancer.  By  this  wo  wish  to  say  that  we  seek  for  the  sub- 
stance of  the  carcinomatous  degeneration  in  a  deposition  in  foci  of  cells 
advancing  in  fixed  directions,  which  necessarily  tends  to  this,  that  we  must 
grant  to  the  parencbyma  of  the  organ  in  process  of  destruction,  which  remains 
between  these  cellular  depots,  the  form  of  a  framework,  a  trabecular  or  net- 
work (stroma),  whose  meshes  (alveoli)  are  determined  by  the  form  and  size 
of  the  deposited  aggregations  of  cells.  It  is  manifest  that  this  structure  is 
particularly  fitted  to  lodge  large  amounts  of  free  cells,  which  we  must 
regard  as  the  most  effective  stimulus  as  well  for  the  local  growth  of  a 
tumor  as  for  the  infection  of  the  entire  organism.  The  seeming  arbi- 
trariness with  which  we  proclaim  the  alveolar  structure  as  the  anatomical 
criterion  of  cancer,  consequently,  receives  its  justification  ;  but  a  new  diffi- 
culty arises,  when  we  reflect  that  then  the  alveolar  sarcomas  must  also  be 
designated  as  carcinomas  ;  tumors,  therefore,  whose  '  permeatiop  by  cellu- 
lar heaps'  (' Durchsetztsein  mit  Zellenhaufen')  we  believed  we  ought  to 
assimilate  with  the  suppuration  of  inflammatory  tissues.  I  accept  this  con- 
sequence, and  thereby  place  myself  upon  the  platform  of  those  who  under- 
stand by  carcinoma  in  essentials  a  clinical  character  that  is  anatomically  but 
imperfectly  expressed  ;  i.e.,  only  in  the  obligatory  alveolar  structure. 

"  The  GREATER  Himiber  hy  far  of  carcinomas  proceed  primarily  either  from 
the  ejnthelial-clad  surfaces  of  the  body,  from,  the  skin  and  m.ucous  membranes, 
or  from  the  secerning  glands.  They  depend  upon  an  abnormal  growth  of  the 
epithelial  tissue.  We  may  say  that  an  ingrowing  of  e])ithelium  into  the 
sub-epithelial  layer  of  connective  tissue  of  membranes  or  into  the  interstitial 
connective  tissue  of  glands  forms  the  fundamental  processes  in  these  carci- 
nomas. The  nature  and  manner  of  the  ingrowing  is  extraordinarily  various. 
The  whole  impression  made  by  a  carcinomatous  destruction — for  example,  the 
observation  of  a  vertical  section  by  alow  magnifying  power — appears  to  justify 
the  opinion  that  in  them  the  question  is  about  a  diseased  imitation  of  those 
histological  processes  which  precede  the  development  of  glands  with  excre- 
tory ducts  ;  namely,  here  as  there  we  see  aggregations  of  epithelial  cells, 
which  proceed  from  the  under  surface  of  the  epithelium  in  the  form  of  cones 
or  strands,  and  insinuate  themselves  between  the  separating  filaments  of  the 
connective  tissue.  Active  processes  of  division  also  show  themselves  in  the 
elements  constituting  the  cell-aggregations,  so  that  in  both  of  these  principal 
points  an  undeniable  uniformity  with  glandular  growth  is  present.  Never- 
theless, the  view  that  the  carcinoma  formation  consists ^n  a  subordinate  and 
irregular  imitation  of  the  physiological  glandular  growth  (heteradenie  of  the 


TUMORS  OF   THE  MOUTH.  897 

inquisitive  and  learned  histologists  of  the  age.  Clinically,  it  is  to  be 
affirmed  that  no  surgeon  lives  who,  upon  the  living  snljject,  or  upon 

French)  has  but  a  verj^  contracted  justifioation.  After  having  above  devotpd 
so  much  time  and  space  to  the  consideration  of  normal  epithelial  growth,  it 
would  ill  become  us  should  we  now  lose  the  fruits  of  that  consideration  by 
an  ill-timed  formation  of  hypotheses.  For  the  carcinomns  of  glands  with 
open  outlets,  of  course  we  \\va\  even  indicate  with  emphasis  that  all  imagin- 
able transitions  between  glandular  lij-pertrophy  and  the  glandular  carcinoma 
are  to  be  found.  We  of  the  latest  time  have  learned  to  know  these  interme- 
diate forms  mofe  fundamentally,  and  have  invented  the  name  adenoma,  to 
designate  a  tumor  which  is  neither  simple  hypertrophy  nor  carcinoma.  This 
is  at  least  the  most  comprehensive  conception  :  several  authors  certainly 
move  the  idea  of  adenoma  up  and  down  upon  the  scale  mentioned,  in  that 
they  now  assign  it  more  to  hypertrophj',  now  more  to  carcinoma;  that,  how- 
ever, a  motion  up  and  down  of  this  kind  is  possible,  just  proves  the  existence 
of  the  scale. 

"  The  general  comprehension,  however,  of  carcinomas,  which  proceed  from 
the  epidermis  or  the  epithelium  of  mucous  membranes,  is  much  more  diffi- 
cult ;  namely,  here  also  exists  an  unmistakable  correlation  of  the  hyperplastic 
and  carcinomatous  conditions.  It  is,  for  example,  a  well  known  experience, 
that  those  circumscribed  hj-pertrophies  of  the  skin,  which  we  term  warts  and 
papillomas,  have  the  capacity  of  going  over  into  epithelial  carcinoma.  This 
transition  is  brought  about  purely  anatomically  in  the  following  manner  : 
the  papillar  hypertrophy  conditions  a  more  or  less  great  alteration  of  the  level 
of  that  plane  in  which  the  epithelium  and  connective  tissue  come  into  con- 
tact. The  steeply-raised  lateral  surfaces  of  the  enlarged  or  newly-produced 
papilliB  bound  deep,  cleft-like  depressions  between  the  papiHie.  The  epithe- 
lial covering  of  the  papillie  is  at  the  same  time  an  epithelial  lining  of  the 
interpapillary  clefts,  and  as  long  as  this  relation  remains  constant  by  a  suffi- 
cient desquamation  of  the  older  epithelial  cells,  the  hyperplastic  character  of 
the  tumor  is  preserved.  It  is,  however,  manifest  that  a  sufficing  desquama- 
tion is  so  much  the  less  possible,  the  more  the  papillae  elongate,  and  especially 
the  richer  their  dendritic  ramification  proves  to  be.  The  lateral  pressure 
which  the  points  of  the  papilla3,  widely  branched  but  united  to  a  narrow  basis, 
exert,  simultaneously  closes  from  above  the  interpapillary  clefts,  and  causes 
in  them  a  gradually  increasing  accumulation  of  epithelial  cells.  The  epithe- 
lium in  the  deeper  parts  of  the  tumor  no  longer  appears  as  a  lijiing,  but  as  a 
solid  plugging  of  the  interpapillai-y  clefts.  As  such  it  now  begins  to  push 
forward  against  various  points  of  the  connective-tissue  substratum.  Oval 
epithelial  cones  appear,  which  first  protrude  from  the  under  surface  of  the 
epidermis  into  the  cutis,  then  penetrate  deeper  and  deeper.  By  this  the  car- 
cinomatous condition  is  given.  We  cannot  of  course  avoid  comparing  these 
cones  with  the  epithelial  cones  in  the  glandular  formation  ;  we  also  observe, 
as  was  said,  lively  processes  of  division  in  the  constituent  cells,  although, 
until  proof  to  the  contrary  has  been  shown,  I  am  convinced  that  tlicir  growth 
chiefiy  depends  upon  a  peripheric  apposition  of  young  cells,  like  the  growth 

56 


898  ORAL  DISEASES  AND   SURGERY. 

the  dead  one  either,  can  mark  a  line  of  distinction  at  any  exact  point 
between  a  fibroma  and  a  carcinoma :  the  author  does  not  affirm  that 

of  normal  epithelium,  and  find  this  representation  just  as  plausible  as  per- 
haps the  enlargement  of  retention-cj'sts  by  the  secretion  from  their  walls.  The 
processes  of  division  in  the  interior  of  the  epithelial  cones  indicate  a  second- 
ary growth  and  may  indeed  contribute  the  greater  part  to  the  thickening  of 
the  epithelial  cones  ;  to  their  elongation,  however,  and  their  forward  progress, 
upon  which  the  peculiar  destruction  of  organs  still  depends,  they  do  not  con- 
tribute. In  that  I,  in  reference  to  the  special  elucidation  of  this  matter,  refer 
to  the  considerations  following  below  of  squamous  epithelial  cancers.  I  con- 
tent myself,  in  these  preliminary  remarks,  to  have  pointed  out  that  the  laws 
of  normal  growth  are  correctly  maintained  even  in  these  extremcst  and  most 
dangerous  excesses. ' ' — Rixdfleisch. 

"  In  the  neck,  salivary  ducts  (closed  internally  and  externally,  but  open  in 
the  middle,  which  are  lined  with  epidermis)  may,  in  the  course  of  years,  be- 
come large  cholesteatomata  by  the  deposit  of  epidermis.  These  show  them- 
selves in  the  mouth  (as  ranula),  or  externally  on  the  neck  above  and  behind 
the  thyroid. 

"  In  the  mucous  membranes,  also,  inspissation  of  the  glandular  mucus,  and 
consequent  hinderance  to  its  evacuation,  may  cause  development  of  mucous 
cysts  ;  but  probably  the  more  frequent  cause  of  retention-cysts  here  is  closure 
of  the  excretory  duct.  The  secretion  in  these  glands  is  usually  a  tenacious, 
often  thick  mucus,  of  a  honey-color  (meliceris),  reddish  yellow,  or  even 
chocolate-brown.  On  microscopical  examination  of  the  contents  of  the  cyst, 
we  find  numerous  large,  pale,  round  cells,  often  containing  fat  globules,  in 
homogeneous  mucus,  also  cholesterine  crystals,  often  in  large  quantities.  In 
the  nasal  mucous  membrane  these  cysts  are  rare^but  they  occur  in  nasal 
mucous  polypi,  often  to  such  an  extent  as  to  give  them  the  name  of  cystic 
polypi.  Liischka  often  found  small  cysts  in  the  mucous  membrane  of  the 
antrum  Highmori.  In  the  oral  mucous  membrane  they  occur  chiefly  on  the 
inside  of  the  lips,  more  rarely  on  the  cheeks  ;  they  are  an  ordinary  occurrence 
in  the  uterine  mucous  membrane  and  in  uterine  polypi.  In  the  rectal  mucous 
membrane,  on  the  contrarj',  mucous  cysts  do  not  occur,  and  they  are  very 
rare  in  the  mucous  membranes  deep  in  the  body. 

"  While  the  above  varieties  of  neoplastic  cysts  have  no  relation  to  gland 
new  formations,  those  we  are  now  about  to  mention  develop  from  adenoma. 
The  cysts  of  the  thyroid,  cystic  goitre,  have  a  somewhat  uncertain  position  in 
this  series  ;  uncertain  because  they  are  not  due  to  newly-formed  gland  follicles 
or  ducts,  but  to  collection  of  mucous  secretion  in  one  of  the  thyroid  vesicles. 
If  we  term  the  contents  of'these  cysts  secretion,  as  we  might  do  for  some  reasons, 
we  must  class  these  cysts  as  retention-cysts.  But,  as  it  might  be  urged  on  the 
other  hand  that  it  would  be  questionable  to  speak  of  a  secretion  of  the  thyroid 
gland,  as  some  state  that  normally  the  contents  of  the  thyroid  vesicles  consist 
solely  of  cells,  we  may  also  consider  the  cysts  resulting  from  softening  of  the 
contents  of  the  vesicles  as  newly  formed.  Whichever  view  we  take,  it  is 
certain  that  the  cysts  of  the  thyroid  may  be  solitary,  and  may  attain  great 


TUMORS   OF  THE  MOUTH.  899 

there  is  not  such  a  line,  but  he  does  affirm  that  if  there  be,  he  has  never 
been  able  to  discover  where  it  is.   When  meeting  with  a  tumor  without 

size.  Moreover,  in  filmost  every  large,  and  in  some  small,  otherwise  firm 
goitres,  one  or  more  cysts  occur  ;  they  usually  have  very  smooth  walls.  The 
large,  isolated  cysts  of  this  variety,  particularly,  give  the  impression  that 
they  are  chiefly  secretion-cysts,  while  other  similar  cavities  in  other  parts  of 
large  goitres,  by  their  softened,  ragged  walls,  give  the  impression  of  being 
softening  cysts.  In  the  thyroid  gland  the  process  of  softening  usually  ter- 
minates in  the  formation  of  a  mucous  fluid  ;  but  there  are  other  cysts  in  these 
glands  that  contain  a  gray,  friable  pulp,  which  looks  like  that  from  sebaceous 
glands,  but  diflers  essentially  from  it  because  it  contains  only  the  detritus  of 
thyroid  tissue  ;  I  have  never  seen  genuine  atheroma  pulp  in  thyroid  cysts. 

"  I  must  lastly  mention  cysts  containing  perfectly  fluid  venous  blood,  and 
having  smooth  walls,  which  are  here  and  there  mentioned  in  literature. 
Some  of  them  refill  rapidly,  others  more  slowly,  after  puncture;  such  cysts 
have  been  observed  in  the  axilla,  on  the  thorax  and  neck.  Excluding  those 
cases  where  effusions  of  blood  have  given  a  dark-blood  color  to  the  mucous 
or  serous  contents  of  a  cyst,  and  considering  only  those  in  which  there  is 
blood  alone  in  the  cj'sts,  they  could  scarcely  have  been  anything  but  large 
sacs  on  the  veins  or  cavernous-venous  tumors  whose  framework  had  been 
entirely  atrophied.  All  the  cases  of  this  kind  so  far  reported  have  been  cured 
bj'  puncture  and  injection  with  iodine,  so  that  nothing  can  be  said  of  the 
pathological  anatomy. 

"  The  diagnosis  of  cystic  tumor  is  easy;  if  it  can  be  certainly  palpated,  the 
fluctuation  will  be  felt ;  deeply-seated  cysts  are  often  diflBcult  to  recognize. 
They  may  be  mistaken  for  other  encapsulated  fluids ;  an  exploratory  punc- 
ture with  a  very  fine  trocar  is  admissible  to  confirm  the  diagnosis,  if  this  be 
necessary  to  determine  the  treatment.  There  are  various  things  for  which  a 
cyst  may  bo  mistaken  ;  e.g.  cold  abscesses  are  also  painless,  occasionally  very 
slowly  enlarging,  fluctuating  tumors ;  also  cystic  parasites,  of  which  two 
varieties  occur  in  the  outer  parts  of  the  body,  especially  in  the  subcutaneous 
tissue  ;  cysticercus  cellulosse  and  echinococcus  hominis,  although  rare,  do  occur 
in  the  cellular  tissue  (and  still  more  rarely  in  bone) ;  the  former  is  a  small, 
the  latter  a  large  vesicle,  which  may  contain  many  smaller  ones  ;  the  vesicle 
of  which  the  animal  consists  always  has  a  neoplastic  sac  around  it;  as  may 
be  readily  seen,  the  whole  thing  gives  the  impression  of  a  cystic  tumor.  I 
have  seen  cysticercus  vesicles  removed  from  the  tongue  and  nose,  echinococcus 
vesicles  removed  from  the  back  and  thigh.  The  diagnosis  of  cysts  was  made 
in  all  the  cases  except  in  one  of  the  latter  where  abscess  was  diagnosed, 
and  in  fact,  instead  of  the  customary  encapsulation,  there  was  suppuration 
around  the  dead  echinococcus  vesicle.  I  have  introduced  this  as  a  sort  of  ap- 
pendix, because  we  have  nowhere  else  an  opportunity  of  considering  the  para- 
sites. The  millions  of  irichinie  occasionally  scattered  through  the  muscles 
cannot  be  treated  surgically,  even  when,  according  to  the  brilliant  investiga- 
tions of  Zenker,  the  diagnosis  may  be,  and  has  been,  made  in  many  cases. 
Dropsies  of  the  subcutaneous  mucous  bursse  and  of  the  tendinous  sheaths,  as 


900  ORAL  DISEASES  AND   SURGEBY. 

such  local  expression  as  described  iu  connection  with  the  first  classi- 
fication, he  knows  of  no  rule  of  any  service  to  the  judgment.     How 

well  as  spina  bifida,  may  also  be  readily  mistaken  for  cj'stic  tumors,  if  we  do 
not  attend  to  the  anatomical  seat  of  these  swellings.  Cystomata  may  also  be 
mistaken  for  other  gelatinous  soft  sarcomata  and  carcinomata,  and  for  very 
soft  fatty  tumors.  As  stated,  when  an  intention  of  operating  renders  a  cer- 
tain diagnosis  necessary,  we  make  an  exploratory  puncture.  But  what  guides 
us  chiefly,  in  the  diagnosis,  is  the  experience  about  the  relative  frequence  of 
different  tumors  on  different  parts  of  the  body  ;  1  have  given  "you  the  sum  of 
these  experiences  in  each  form  of  cyst,  and  in  the  clinic  shall  hereafter  direct 
your  special  attention  to  this  jjoint. 

"  As  the  above  includes  the  prognosis  of  cystic  tumors,  all  of  which  grow 
slowly  when  they  exist  as  cysts  without  complication,  we  may  i)ass  at  once  to 
their  treatment.  We  may  remove  cysts  in  two  ways,  viz.  :  by  evacuating  the 
contents,  and  locally  applying  remedies  that  may  excite  an  inflammation 
which  shall  cause  atrophy  of  the  sac,  or  by  extirpating  the  sac  ;  the  latter  is 
always  the  simplest  and  most  rapid,  and  we  always  give  it  the  preference 
where  it  can  be  done  easily  and  without  danger  to  life.  But  in  cysts  of  the 
ovary,  thyroid,  and  other  glands,  that  are  deeply  seated  or  from  other  causes 
dangerous,  some  other,  safer  operation  is  of  course  desirable,  if  it  others  a  pros- 
pect of  success.  We  may  induce  shrinkage  of  the  sac  after  precedent  evacu- 
ation of  the  contents,  by  a  suppurative  or  by  a  milder,  drier  inflanunation. 
If  you  slit  up  the  wall  of  the  cyst  its  whole  length,  and  keep  the  cut  edges 
apart,  there  will  be  suppuration  and  granulation  of  the  exjiosed  inner  wall  of 
the  cyst,  with  detachment  of  the  portions  of  tumor  or  ej)ithelium  clinging  to 
it;  the  sac  then  gradually  shrinks  up  into  a  cicatrix,  then  decreases  in  size, 
and  finally  heals  ;  but  this  may  require  months.  You  may  attain  the  same 
thing  in  a  more  subcutaneous  way,  by  ligatures  or  tubes  through  the  tumor 
at  different  points  ;  the  irritation  caused  by  these,  as  well  as  by  the  entrance 
of  air,  causes  suppuration  and  granulation  of  the  inner  wall,  and  in  favor- 
able cases  the.se  may  lead  to  atrophy  ;  often  this  does  not  occur  in  the  manner 
desired,  or  else  it  may  require  mcmths  or  years  ;  so  that  of  these  two  methods 
the  first  is  j)referable  ;  it  is  particularly  applicable  to  cysts  of  the  neck.  We 
may  attain  shrinkage  of  the  cyst  and  drying  up  of  its  contents  in  another 
way,  namely,  by  puncture,  with  subsequent  injection  of  tincture  of  iodine  ; 
we  have  already  said  enough  about  the  effect  of  this  treatment.  Here, 
too,  the  injection  is  followed  bj'  severe  inflammation  of  the  .«ac  with  sero- 
fibrinous exudation;  then  the  serum  is  reaVjsorbed  and  the  sac  contracts.  The 
latter  method  is  particularly  ajiplicable  when  we  have  to  deal  not  with  con- 
tents of  softened  tissue,  but  with  a  fluid  secreted  by  the  walls  of  the  sac,  that 
is,  chiefly  with  cy.<ts  whose  contents  are  serous,  and  some  sorts  of  mucous 
cysts.  Cystomata  developed  from  softened  gelatinous  substance  and  fat-cysts 
are  not  suited  for  iodine  injections  ;  for  thej'  are  apt  to  be  followed  by  severe 
inflammaticm  and  suppuration,  with  formation  of  gas,  so  that  we  are  subse- 
quently obliged  to  slit  up  the  entire  sac.  And  very  thick  walls,  which  contract 
very  slowly  or  not  at  all,  also  contra-indicate  iodine  injections.  Hence  among 


TUMORS   OF   THE  MOUTH.  901 

harmless  or  how  malignant  a  non-explainable  tumor  is  to  prove 
can  only  be  judged  by  an  experience  that  has  seen  much  of  such  prac- 

cysts  of  the  neck  we  find  some  that  are  suited  for  this  treatment,  others  which 
are  not,  because  their  walls  are  too  thick.  Of  the  ovarian  cysts,  too,  unfortu- 
nately hut  few  are  suited  for  treatment  by  iodine  injection,  s'o  that  recently 
the  extirpation  of  these  tumors  by  laparotomy  is  considered  the  only  certain 
operative  proceeding  ;  of  late  years  the  results  from  this  operation  have  con- 
stantly been  growing  more  favorable.  Lastlv,  we  must  state  that  in  some 
cases  it  is  best  to  avoid  any  operation  ;  for  instance,  T  should  consider  it  folly 
to  persuade  an  old  man,  with  a  number  of  atheromata  on  his  head,  to  have 
them  removed  ;  for,  if  the  operation  were  followed  by  erysipelas,  it  might 
prove  fatal. 

"  The  common  clinical  definition  of  carcinoma  should  be  controlled  bj'  the 
anatomical  structure  of  these  tumors.  Anatomical  peculiarities,  easily  recog- 
nized with  the  naked  ej'e  or  with  the  microscope,  are  sought  for.  The  classi- 
cal monographs  of  Astley  Cooper  on  diseases  of  the  testis  and  breast  (the  latter, 
unfortunately,  unfinished)  show  that  by  a  careful  study  of  the  points  percep- 
tible to  the  naked  eye,  a  great  deal  may  be  attained  by  studying  a  single 
organ  ;  but  a  generalization  by  aid  of  the  anatomical  preparations  alone  is 
impossible,  as  we  have  often  felt,  in  the  course  of  these  lectures — it  is  fre- 
quently diflScult,  even  with  our  present  aids  ;  so  that  I  cannot  blame  Virrhow 
for  trying,  in  his  great  work  on  tumors,  to  give  most  minute  descriptions  of 
the  different  forms  of  tumors  at  certain  localities.  Here,  where  we  must  ex- 
press ourselves  briefly,  to  give  our  descriptions  an  anatomical  basis,  we  must 
be  somewhat  more  decided  and  summarJ^  When  the  naked  eye  no  longer 
sufficed  for  the  diagnosis  of  tumors,  the  aid  of  the  microscope  was  invoked, 
and  characteristic  appearances  were  sought  that  might  occur  in  the  same  way 
in  all  the  tumors  we  have  described.  Still,  whether  the  characteristics  of  the 
cellular  elements  were  sought  in  their  processes,  the  size  of  the  nucleus  or  of 
the  nucleolus,  the  clinical  and  anatomical  peculiarities  would  not  always  re- 
main congruous.  When  the  cells  proved  inefficacious  as  evidence  of  carci- 
noma, it  was  sought  for  in  the  general  structure  of  the  tumor;  alveolar 
formation  was  asserted  to  be  the  anatomical  peculiarity.  We  even  come  in 
collision  with  this  idea  occasionally  ;  the  net-like  formation  of  neoplastic 
lymphatic  gland-tissue  may  also  be  termed  '  alveolar,'  and  even  acknowledg- 
ing that  the  lymphoma  net-work  is  so  peculiarly  characterized  by  its  form 
that  it  may  be  readily  excluded,  there  still  remain  some  forms  of  chondro- 
mata  and  sarcomata,  especially  the  giant-celled  and  other  large-celled  sar- 
comata forms,  which  we  have  already  designated  as  alveolar  sarcomata,  as 
the  ghosts  of  cancer. 

"  The  more  I  feel  obliged  to  suppose  that  in  the  perfect  organism  there  are 
no  entirely  indifferent  cells,  but  that  the  elements  of  the  middle  germ  layer 
of  the  embryo  and  of  the  two  epithelial  layers  are  always  somewhat  iji  oppo- 
sition, the  more  I  am  inclined  to  use  this  fundamental  histogenetic  fact  for 
the  development  and  division  of  tumors.  In  accordance  with  this,  I  only 
call  those  tumors  true  carcinomata  which  have  a  formation  similar  to  that  of 


902  ORAL  DISEASES  AND   SURGERY. 

tice.  If  this  is  lack  of  wisdom,  then  is  it  a  necessity  to  admit  that 
there  is  no  malignant  dyscrasia,  but  that  local  differences  of  disease 
depend  strictly  upon  local  causes. 

true  epithelial,glands  (not  the  lymphatic  glands),  and  whose  cells  are  mostly 
actual  derivatives  from  true  epithelium.  I  am  convinced  that  this  view  will 
constantly  have  more  adherents,  and  that  thus  the  difference  about  the  ana- 
tomical definition  of  '  carcinoma'  will  constantly  diminish.  Those  investi- 
gators who,  during  the  last  few  years,  with  all  the  modern  aids,  have  worked 
without  prejudice  on  this  portion  of  the  study  of  tumors,  recognize  the  great 
importance  of  epithelial  proliferation  in  those  tumors  that  we  call  cancer  ; 
still,  most  of  them  seek  for  a  compromise  between  the  different  histogenetic 
views,  and  wish  still  to  admit,  in  a  modified  form,  the  development  of  truB 
glandular  and  epithelial  cells  from  connective  tissue  (heterology  proper)  [Rind- 
fleisch,  Volknia.jin,  Klebs,  Liicke) ;  on}y  T/iieiSch,  and  recently  Waldeyer,  main- 
tain, as  I  do,  the  strict  boundary  between  epithelial  and  connective-tissue 
cells.  Waldeyer  defines  carcinoma  as  an  atypical  epithelial  neoplasm.  But 
we  must  here  state  that  in  cancer-tumors,  besides  the  epitheliums,  there  are 
usuall}'  numerous  young,  small  round  cells  which,  infiltrated  in  the  connective- 
tissue  portion  of  the  tumor,  form  an  important  part  of  it.  This  small-celled 
connective-tissue  infiltration,  which  exists  in  varying  quantities  wherever 
epithelial  proliferations  grow  into  the  tissue,  a])pears  to  be  caused  by  a  sort 
of  reaction,  and  to  be  the  result  of  the  penetration  of  the  epithelial  new  for- 
mations into  the  tissue,  according  to  the  number  of  infiltrated  cells  and  their 
future  fate,  as  well  as  the  degree  of  vascularity,  just  as  in  inflammation  it 
sometimes  leads  to  softening,  to  atrophy,  and  cicatricial  thickening  of  the 
tissue.  In  some  cases  this  small-celled  infiltration  is  so  considerable  as  almost 
entirel}-  to  hide  the  epithelial  new  formation  (from  which  it  may  be  very  diffi- 
cult to  distinguish,  if  the  latter  be  small).  "We  may  then  be  in  doubt  if  it 
should  not  be  regarded  as  entirely  independent,  and  occasionally,  perhaps,  as 
the  sole  constituent  of  cancerous  tumors.  Formerly  I  myself  thought  it 
necessary  to  agree  to  this,  and  even  supposed  that  this  component  of  carcinoma 
possessed  a  spontaneous  power  of  infection  ;  but  further  observations  with 
new  aids  have  made  it  appear  to  me  more  probable  that,  even  in  the  smallest 
cancerous  nodules,  epithelial  elements  always  gave  the  first  start  for  develop- 
ment.    This  has  been  confirmed  by  V/nldcyer. 

"  It  is  especially  important  to  make  a  distinction  between  adenoma  and  car- 
cinoma, as  the  two  forms  of  tumors  have  some  points  in  common.  Pui-e  ade- 
nomata are  composed  of  newly-formed  gland-substance  which  is  entirely 
analogous  to  or  at  least  very  much  like  the  normal ;  the  connective  tissue 
around  the  newly-formed  acini  has  the  same  relation  to  them  as  to  the  normal. 

"  In  adeno-sarcoma  there  is  little  if  any  new  formation  of  glandular  acini, 
but  the  sarcoma  merely  incloses  the  glandular  spaces  which  have  remained 
normal," or  are  dilated.  But  it  is  characteristic  of  carcinoma  that  the  epithe- 
lial covering  of  a  skin  or  mucous  membrane,  or  the  epithelial  lining  of  glan- 
dular cavities,  grows  into  the  skin,  and  even  deeper,  in  the  form  of  roundish 


TUMORS   OF   THE  MOUTH.  903 

Carcinoma,  as  the  jaws  are  concerned,  may  be  studied  under  tlie 
expressions  of  histoid    mixed   tumors,  scirrlius,  sarcomatous   sar- 

nodules  (acinous),  or  of  round  cylinders  or  rollers  (tubular),  just  as  occurs  in 
the  foetus.  While  so  doing,  the  epithelial  cells  usually  preserve  their  form, 
only  they  often  grow  much  larger  than  normal.  The  form  of  the  glands 
from  which  these  formations  proceed  generally  rerriains  typical  for  the  neo- 
plasm also ;  but  it  remains  in  irregular  forms  of  glands  ;  it  is  only  rarely  that 
cavities  are  formed,  and  that  actual  secretion  goes  on  in  these  cavities.  Be- 
sides the  epithelial  parts  of  these  tumors,  the  connective  tissue,  bones,  muscles, 
etc.,  into  which  the  epithelium  enters,  conduct  themselves  as  follows:  We 
sometimes  find  them  of  normal,  again  of  abnormal  firmness,  sometimes  verj'' 
soft,  almost  raucous,  ordinarily  in  less  quantity  than  the  epithelial  masses.  It 
is  usually  pervaded  by  small,  round  (lymph)  cells,  often  to  such  an  extent  that 
scarcely  any  fibrous  tissue  is  left ;  generally  the  infiltrated  small  cellular  ele-. 
ments  are  scattered  diflfusely  in  the  cancerous  (connective-tissue)  framework  ; 
very  rarely  we  find  numerous  cells,  collected  together  in  a  fissure  between 
the  connective-tissue  bundles.  When  the  tumor  advances  into  the  bone,  the 
latter  is  eaten  away,  as  in  caries.  I  have  not  been  able  to  satisfy  myself  that 
there  is  any  new  formation  of  connective-tissue  filaments  in  the  nodular  and 
infiltrated  forms  of  these  tumors,  nor  have  I  been  able  to  find  any  osseous 
new  formation  ;  but  there  is  no  doubt  that  such  a  new  formation  occurs  in  the 
papillary  and  villous  forms,  of  which  we  shall  hereafter  speak.  From  this 
description  you  see  that  IVaideyer's  expression  about  the  epithelial  formation 
in  carcinoma  being  atypical,  [tissu  hcth'oadenique  of  Robin)  is  also  well  suited 
for  distinguishing  carcinomata  from  adenomata,  as  typical  new  formations. 

"  As  regards  the  vessels  in  these  tumors,  we  may  satisfy  ourselves,  by  artifi- 
cial injections,  that  the  dilatation  and  new  formation,  by  tortuosity  and  loop- 
ing, are  considerable;  only  the  connective-tissue  portions  of  the  tumor  are 
vascularized,  the  epithelial  portions  remain  free.  I  cannot  go  any  further 
into  the  general  histological  description  of  these  tumors,  and  hope  that  they 
may  be  recognizable  from  the  above,  although  I  acknowledge  that  it  is 
sometimes  very  difficult  to  distinguish  carcinoma  from  adeno-sarcoiiia  and 
alveolar  sarcoma. 

"  According  to  my  whole  histogenetic  view,  I  must  regard  it  as  impossible 
for  an  epithelial  cancer  to  occur  primarily  in  a  bone  or  lymphatic  gland.  The 
observations  that  I  know,  to.  this  efl'ect  (in  the  lower  jaw,  on  the  anterior 
surface  of  the  tibia,  in  the  lymphatic  glands  of  the  neck),  do  not  seem  to  me 
sufiicient  proof,  because  the  skin  and  mucous  membrane  are  so  near ;  there 
may  have  been  an  insignificant  carcinomatous  disease  of  the  skin  or  mucous 
membrane  as  a  starting-point  of  the  disease,  without  its  having  been  noticed. 

"  The  appearance  of  the  cut  surface  of  this  tumor,  and  its  consistence,  vary 
so,  that  no  general  description  can  be  given  of  it. 

"  In  the  great  majority  of  cases,  carcinoma  appears  in  the  form  of  nodules  ; 
also  as  indurations  of  otherwise  soft  tissues,  or  as  papillary  proliferations. 
Barely,  the  diseased  parts  are  separated  from  the  healthy  tissue  by  a  connective- 
tissue  capsule ;  but,  in  most  cases,  the  passage  from  healthy  to  diseased  tissue 


904  ORAL  DISEASES  AND  SURGEBY. 

coma,  the  telangiectatic  and  encephaloma :  these,  as  understood, 
are  merely  arbitrary  divisions,  and  might,  with  all  histological  pro- 
priety, be  enlarged  to  include  the  many  other  expressions  belonging 
to  the  class.     (Refer  to  works  on  Pathological  Histology). 

Histoid  Mixed  Tumors.* — The  tumors  described  as  fibromata, 


is  more  gradual.  In  some  cases  there  is  no  cancerous  tumor,  but  a  cancerous 
infiltration,  there  being  no  enlargement,  possibly  even  a  diminution  in  size 
of  tiie  aifected  organ.  It  is  also  characteri.^tic  of  carcinoma  that  part  of  the 
new  formation  is  very  short-lived,  disintegrates  directly  or  after  precedent 
fatty  degeneration,  is  reabsorbed,  and  then  the  infiltrated  fibrous  tissue  con- 
tracts to  a  firm  cicatrix.  Besides  this  cicatricial  shrinking,  and  not  unfre- 
quently  along  with  it,  there  is  often  softening ;  it  is,  perhaps,  even  more 
frequent  than  contraction  ;  at  all  events,  it  is  more  extensive.  This  soften- 
ing is  mostly  preceded  by  fatty  degeneration  of  the  cells  and  caseous  meta- 
morphosis; central  softening,  opening  outwardly,  fsrmation  of  a  putrid  ulcer, 
with  fungous  edges,  is  very  characteristic  of  carcinoma.  Mucous  metamor- 
phosis of  the  cell-protoplasm  also  takes  place  in  some  glandular  carcinomata, 
relatively  most  often  in  those  of  the  liver,  stomach,  and  rectum;  in  rare 
cases,  this  also  affects  the  connective-tissue  stroma.  This  mucous  cancer  is 
also  called  gelniinous  or  colloid.  When  cancerous  degenerations  occur  on  the 
surface,  the  papillary  layer  may  develop  so  as  to  become  very  prominent,  as 
in  some  pnpiUa7-y  cancers  (destructive  papillomata)  of  the  mucous  membrane 
of  the  lips,  stomach,  and  portio  vaginalis,  and  as  in  villous  cancer,  which  de- 
velops on  the  mucous  membrane  of  the  bladder,  in  the  form  of  dendritic, 
branched,  large  papillae.  If  the' cicatricial  contraction  predominate  in  a  car- 
cinoma (as  it  does  in  some  forms  of  cancer  of  the  breast),  hard  tumors  or  ulcers 
are  developed,  which  have  for  ages  been  called  scirrkus.  Some  carcinomata 
are  brown  or  black,  but  still  melano-carcinomaia  are  rare.  Most  soft  melano- 
mata  are  sarcomata.  You  will  more  readily  acquire  an  idea  of  the  different 
forms  of  cancer  by  studying  attentively  their  origin  and  the  localities  where 
they  chiefly  occur."— Billroth. 

*  '^'^ Histoid  Tumors. — In  the  capabilitj'  of  the  intermediary  nutritive  appa- 
ratus, of  producing  embrycmal  coniiective  tissue  at  almost  every  point  of  the 
body,  those  higher  histogenetic  actions  are  also  founded,  which  we  in  the 
more  contracted  meaning  of  the  word  term  excrescences,  more  correctly, 
however,  histoid  tumors.  The  interior  continuity  of  their  elementary  parts 
is  characteristic  of  histoid  tumors.  The  majority  of  them  consist  generally 
onlj'  of  one  tissue  ;  where,  however,  more  tissues  participate  in  the  compo- 
sition, they  are  never  found  in  a  diflferential  apposition  determined  by  sharp 
limits  as  epithelium  and  connective  tissue,  but  they  organically  pass  into 
each  other.  This  intimate  continuity  is  declared  also  from  the  original  interior 
uniformity  of  the  foundation  of  the  tumor,  which  in  all  cases  is  given  by  a 
certain  amount  of  embryonal  formative  tissue.  From  this  only  by  subsequent 
differentiation  do  the  higher  types  of  tissues  proceed,  and,  indeed,  with  a  pe- 
culiar predilection  the  connective  substances,  the  connective  tissue  itself  with 


TUMORS   OF   THE  MOUTH.  905 

sarcomata,  etc.  possess  their  appellation  from  a  distinctiveness  of 
tissue  which  characterizes  them  in  their  purest  expression.  In  the 
histoid  mixed,  two  or  more  elements  are  found  conjoined,  thus,  as  is 
seen,  confusing  necessarily  classification  by  such  distinctions.  When, 
as  has  been  queried  by  Rindfleisch,  besides  distinct  lipomatous  con- 
stituents, distinct  chondromatous  features  are  found  ;  when  sarcoma 
nodes  and  nodules  are  deposited  in  an  enchondroma,  we  do  not  know 
whether  we  should  name  this  thing  enchondroma  lipomatodes,  or 
lipoma  cartilagineum,  or  sarcoma  cartilagineum,  or  chondroma  sar- 
comatosum. This  embarrassment  recurs  with  the  question  as  to  the 
clinical  character  of  this  sort  of  tumor,  the  prognosis,  etc.  The  his- 
toid mixed  tumors,  as  has  been  shown,  will,  in  the  mouth,  be  found 
more  common  than  the  pure  histoid  ;  their  nature  and  character,  from 
what  has  preceded,  will  iie  appreciated. 

SciRRHUs. — Although  the  very  rarest  of  the  expressions  of  the 
cancer  vice  as  met  with  in  the  mouth,  yet  as  a  form  of  the  dyscrasia 
clinical  attention  will  oeca.sioiially  be  directed  to  the  condition. 
Scirrhus  is  a  condition  of  adult  life,  rarely  appearing  before  the  age 
of  forty,  and  even  then  seeming,  in  its  isolation,  a  something  concen- 
trating itself  for  purposes  of  operative  relief  Commencing  in  the 
gum  or  alveoli,  and  secondarily  affecting  the  bone,  scirrhus  ap- 
pears as  a  small  nodule,  incompressible,  having  indeed  a  lead-like 
feel.  What  now  is  to  be  its  progress  depends  pre-eminently  on  cir- 
cumstances.    The  author  has  at  the  present  time  under  charge  a 

its  varieties  (fibroma  and  sarcoma)  occurring  in  the  inflammatory  process,  the 
cartihiginous  tissue  (chondroma),  the  osseous  tissue  (osteoma),  the  adipose 
tissue  (lipoma),  the  mucoid  tissue  (mj'xoma),  the  higher  anomalous  tissues, 
the  muscular  tissue  (myoma),  and  the  nervous  tissue  (genuine  neuroma)  are 
more  rarely  produced.  The  manner  of  the  production,  again,  is  exactly  the 
same  as  in  foetal  development;  that  is  to  saj',  a  certain  amount  of  embryonal 
formative  cells  are  converted  into  cartilage,  bone,  fat,  and  muscle-cells,  while 
the  remainder  is  converted  into  connective  tissue,  and  beyond  this  the  whole 
is  divided  byasuflBcient  vascularization  into  nutritive  territories  of  the  entire 
organism..  Herewith  upon  the  one  hand  the  connection  of  the  tissues  among 
themselves  is  preserved,  upon  the  other  these  with  the  organism  ;  the  new 
formation  appears  as  an  organ,  although  defectively  built  and  unnecessary. 
Without  the  integrity  of  the  body  being  attacked,  colossal  new  formations 
often  arise,  which  need  only  to  be  removed  by  the  knife,  in  order  to  re-estab- 
lish tlie  previous  status. 

"  What  I  last  said,  of  course,  does  not,  however,  obtain  without  restriction. 
Unfortunately,  there  are  also  among  the  histoid  tumors  a  number  to  which 
we  must  ascribe  a  pernicious  character,  malignitas." — Kindfleisch. 


906  OBAL  DISEASES  AND   SURGERY. 

scirrhous  tumor  associated  with  the  periosteum  immediately  beneath 
the  left  malar  bone,  which  made  its  appearance  in  1859  :  this  tumor 
grows  neither  larger  nor  smaller,  being  held  in  abeyance  either  by  the 
lightness  of  the  dyscrasia  or — what  amounts  to  precisely  the  same 
thing — the  resistive  powers  of  the  antagonizing  life-forces.  A  second 
case  is  a  lady,  still  under  care,  from  whose  under  lip,  two  years  back, 
was  removed  a  tumor  yielding  the  microscopic  expression  of  scirrhous 
carcinoma,  and  with  whom  there  has  been  no  return  of  the  disease. 

As  a  scirrhus  advances  in  its  development,  there  becomes  asso- 
ciated with  it  a  lancinating  character  of  pain  particularly  diag- 
nostic, the  presence  of  which  is  commonly  admitted  to  decide  any 
existing  doubt.  Still  advancing,  the  overlying  structures  become 
implicated,  the  skin  contracts  and  adheres,  and  soon  shows  an 
increased  vascularity ;  later  in  its  progress  the  tumor  puts  on  the 
character  of  a  pointing  abscess,  or  ulcerates  with  a  lupoid  expres- 
sion, or  cracks;  finally  the  telangiectatic  expression  is  assumed, 
exuberant  granulations  springing  forth,  giving  to  the  patient  the 
disgusting  associations  of  the  fungus  hiematodes,  and  soon  wearing 
*out  the  life-forces. 

The  diffusion  of  scirrhus  should  be  one  of  the  most  interesting, 
as  it  is  certainly  one  of  the  most  imi)ortant,  matters  of  surgery.  At 
first  appearing  as  a  solitary  nodule,  the  tendency  in  the  condition  to 
multiply  its  expressions  is  a  sufficiently  recognized  fact.  The  author 
has  been,  of  course,  understood  as  indorsing  the  humoral  theory, 
believing  in  a  preliminary  dyscrasia  of  which  a  tumor  is  simply  the 
expression  ;  but  there  is  the  other  side  to  the  question,  and  nowhere 
better  than  just  here  may  its   arguments  be  introduced.*      (See 

*  "Let  us  now  go  more  minutely  into  the  etiology  of  tumors.  Here  we 
should  propose  to  find  the  differences  and  points  of  resemblance  between  the 
processes  causing  inflammatory  neoplasia;  and  tumors.  Let  us  start  with  the 
causes  of  inflammation,  and  compare  them  with  those  of  tumors.  Many 
acute  inflammatory  processes  (exanthemata,  typhus,  etc.),  and  some  chronic 
ones  (intermittents,  scorbutus,  etc.),  are  due  to  miasmata  and  contagions, 
which  enter  the  body  from  without.  I  do  not  know  any  acute  miasmatic  tumors ; 
but  goitre  must  be  considered  as  a  chronic  endemic  miasmatic  tumor  ;  goitre 
cannot  be  regarded  as  a  product  of  inflammation,  as  it  never  spontaneously 
retrogrades,  suppurates,  or  shrinks  up  into  a  cicatrix  ;  the  cause  is  a  specific 
external  one,  to  which  every  one,  especially  the  young,  is  occasionally  ex- 
posed, who  comes  into  a  country  where  goitre  is  endemic;  all  are  not  equally 
disposed  to  it,  there  may  be  an  hereditary  tendency  ;  infection  probably 
occurs  through  the  blood;  at  least,  we  cannot  well  imagine  how  the  thyroid 


I 


TUMORS   OF   THE  MOUTH. 


907 


foot-note;  see  also  "Cellular  Pathology,"  by  Virchow,  pages  90  to 
100,  and  252  to  254;  also,  Essay  of  Mr.  Moore,  "Holmes's  System 
of  Surgery." 

After  the  removal  of  a  single  scirrhous  nodule,  the  recurrence,  if 
it  takes  place,  is  apt  to  be  in  the  form  of  numerous  secondary  papules, 
or  else  with  a  medullary  ex- 
pression. Fig.  276  exhibits 
almost  photographically  this 
disease  as  it  made  its  reap- 
pearance in  the  mamma  of  a 
Jady  from  whose  axilla  the 
author  had  removed  a  scir- 
rhous gland.  In  its  medul- 
lary expression  the  disease 
may  occur  in  the  site  of  re- 
moval, but  it  is  more  prone 
to  reappear  in  the  viscera. 
When  occurring  in  a  viscus, 
the  cachexia  is  quickly  made 

evident,    the    countenance    be-        a  view  of  the  numerous  iiod,ilate,Uumors  which 

often  form  in  the  cicatrix  after  the  extirpation  of  the 
coming     leaden     in      hue,     the     former  growth.    One  is  represented  as  ulcerated  in 

features  pinched,  and  the  lips  ^'''^  ^"®  "^  ">«'  mammiiia.  (After  Miiier.) 
livid.     (See  Paget,  on  the  Cancerous  Diathesis.) 

Concerning  duration,  scirrhus  is  apt  to  complete  its  history  in 


gland  should  be  infected  by  local  infection.  Hence  goitre  is  probablj"^  the 
local  expression  of  a  general  infection,  which  occasionally  evinces  itself  in 
the  whole  nutritive  state,  especially  in  anomalous  development  of  the  skeleton 
and  its  results  (cretinism).  "We  may  also  consider  leontiasis  and  Oriental 
elephantiasis  as  chronic  miasmatic  infections,  in  which  large  masses  of  nodu- 
lar fibrous  tumors  form  in  the  skin  on  different  parts  of  the  body.  Still,  I 
acknowledge  that  this  is  disputed  territory,  and  that  reasons  maybe  advanced 
for  classing  these  among  the  chronic  inflammatory  diseases,  instead  of  among 
tumors.  As  regards  local  infection,  or  the  transfer  of  fixed  contagions  from 
without,  we  know  that  inflammations  of  various  kinds  may  be  thus  induced. 
By  putrid  substances  only  inflammations  are  induced  ;  here  I  class,  also,  the 
so-called  'dissecting  tubercle,'  which  I  cannot  consider  as  a  tumor,  because 
it  disappears  spontaneously,  as  soon  as  new  infection  ceases  to  occur.  Inflam- 
mation is  excited  by  inoculation  with  pus  ;  the  character  of  the  j)us  determines 
the  specific  nature  of  the  inflammation  ;  pus  mny  also  excite  a  constitutional 
disease,  which  again  may  evince  itself  by  multiple  localized  processes,  as  in 
syphilis.  Can  tumors  be  induced  by  inoculation  with  the  juices  of  tumors, 
or  with  small  portions  of  them  ?     This  is  a  disputed  point ;  I  consider  it  pos- 


908  OBAL   DISEASES  AND  SURGERY. 

from  two  to  three  years,  although,  as  has  been  remarked,  cases  may- 
remain  in  abeyance  for  many  years. 

sible,  but  not  proved;  the  difficulty  of  coming  to  a  decision  lies  in  the  fact 
that  it  is  not  allowable  to  make  such  experiments  on  men.  When  such 
experiments  often  fail  on  the  lower  animals,  it  only  shows  that  tumors  from 
man  are  not  transferable  to  them  ;  tumors  from  beasts  must  be  inoculated  on 
beasts  of  like  species ;  a  few  such  experiments  have  been  made  by  Douirele- 
pont,  in  which  the  inoculations  of  carcinoma  from  dogs  on  dogs  had  no  effect. 
At  all  events,  we  cannot  induce  a  tumor  by  inoculating  with  pus,  which  again 
seems  to  show  the  specific  difference  of  the  products.  Perhaps  some  patholo- 
gists may  here  answer  that  '  molluscum  contagiosum'  is  an  example  of  tumor- 
juice  or  constituents  of  tumors  being  inoculable  on  other  persons.  This  fact, 
which  has  been  proved  by  Ebert  and  Virchow,  is  very  interesting ;  still,  the 
right  of  molluscum  contagiosum,  a  cystoid  secretion-hyperplasia  of  the  seba- 
ceous glands,  a  sort  of  large  comedones,  as  well  as  that  of  retention-cysts 
generally,  to  a  position  among  tumors  is  disputed  ;  and,  moreover,  the  con- 
tagiousness of  this  neoplasia  is  still  too  isolated  for  us  to  draw  any  valuable 
conclusions  from  it.  The  most  striking  proof  of  tlje  distinctness  of  inflam- 
matorj'  products  and  tumors  is  offered  by  observation  of  the  local  and  general 
infection,  which  we  have  innumerable  opportunities  of  making.  We  have 
previously  said  a  good  deal  about  progressive  and  secondary  inflammation  of 
acute  lymphangitis,  which  is  always  secondary  (deutcropathic,  Virchoio),  of 
the  secondary  acute  and  chronic  swellings  of  the  lymphatic  glands  in  acute 
and  chronic  inflammations,  especially  of  the  extremities  ;  I  then  told  you  that 
I, considered  it  more  probable  that  cellular  elements  from  the  focus  of  inflam- 
mation passed  into  the  lymphatic  glands,  and,  by  their  specific  phlogogenous 
action,  induced  inflammation  in  the  glands,  which  were  analogous  to  the 
primary  peripheral  inflammations;  tumors  never  develop  through  such  local 
infections  from  inflammatory  foci;  if  the  primary  inflammatory  focus  be 
removed,  the  swellings  of  the  lymphatic  glands  also  disappear.  Similar 
infectious  peculiarities  also  occur  in  many  tumors,  especially  those  which, 
like  the  inflammatory  neoplasia,  are  very  rich  in  cells;  not  only  may  the 
immediate  vicinity  be  infected,  and  numerous  new  foci  be  formed  immedi- 
ately around  the  first  nodule,  but  very  often  the  lymphatic  glands  are  also 
affected,  and  secondary  tumors  form  in  them,  which  have  the  same  peculiari- 
ties as  the  primary ;  nor  are  they  any  more  apt  to  disappear  spontaneously 
than  the  primary,  even  when  the  latter  is  removed;  on  the  contrary,  similar 
tumors  then  frequently  appear  in  other  quite  remote  parts  of  the  body — 
metastatic  tumors.  Here  you  again  have  the  analogy  with  the  course  of 
infection  in  inflammation,  as  well  as  the  specific  distinction,  for  metastatic 
growths  never  result  from  phlogistic  infection,  any  more  than  metastatic 
abscesses  in  internal  organs  do  from  infection  by  a  tumor.  Infection  is  not 
common  to  all  tumors,  although,  unfortunately,  the  majority  are  infectious ; 
these  are  called  malignant,  in  contradistinction  to  the  benign,  or  non-infec- 
tious. It  is  difficult  to  say  on  what  this  difference  is  based ;  it  is  probably 
partly  due  to  the  nature  and  specific  character  of  the  element,  in  their  easy 


TUMORS  OF   THE  MOUTH.  909 

Section  of  an  amputated  malignant  scirrhus  shows  a  concave  sur- 
face, deemed  to  be  very  diagnostic  of  malignancy ;  it  is  smooth,  being 

mobility,  and  in  the  fact  that,  like  the  seed  of  some  of  the  lower  plants,  they 
find  almost  everywhere  soil  suited  for  their  development,  and  can  grow  in 
most  tissues  of  the  body  :  probably  it  is  also  partly  due  to  the  fact  that  the 
conditions  are  more  or  less  favorable  to  the  entrance  of  the  elements  of  the 
tumor  into  the  lymph  or  blood-vessels;  for  instance,  it  is  remarkable  that 
frequently  very  soft  tumors  (medullary  sarcoma)  consisting  almost  entirely 
of  cells,  when  surrounded  by  a  firm  connective-tissue  capsule,  cause  no  infec- 
tion of  the  lymphatic  glands  ;  we  notice  the  same  thing  in  some  large  encap- 
sulated abscesses.  In  regard  to  metastatic  abscesses,  I  have  already  told  you 
that,  according  to  my  view,  they  are  due  to  embolism  ;  we  should  have  to 
seek  another  explanation  of  difl'use  metastatic  inflammations.  Diflfuse  metas- 
tatic tumors  are  very  rare ;  I  should  apply  this  term  only  to  a  few  forms  of 
pleural  and  peritoneal  carcinoma  or  sarcoma.  As  regards  the  mode  of  origin 
of  metastatic  tumors,  the  actual  course  of  the  infection,  from  analogy,  it 
seems  very  probable  that  they,  like  the  secondary  tumors  of  the  lymphatic 
glands,  are  induced  by  seed  from  the  primary  tumors,  or  from  the  tumors  in 
the  lymphatic  glands.  I  acknowledge  I  am  much  inclined  to  this  supposition. 
Although  I  could  not  formerly  believe  that  the  cells  from  a  focus  of  inflam- 
mation or  from  a  tumor  could  be  as  independent  as  thistle-down,  still,  I  think 
that,  with  our  present  knowledge  about  the  independent  life  of  pathologicalh'- 
neoplastic  cells,  there  can  be  no  doubt  of  the  possibility  of  such  a  process. 
Although,  on  the  first  development  of  a  tumor,  as  on  the  occurrence  of  an 
inflammatory  new  formation,  the  lymphatic  vessels  are  partly  closed,  and 
may  be  filled  with  cells,  still,  subsequently,  from  compression,  lymphatic  and 
"Vascular  thrombi  may  form,  into  which  specific  tumor-elements  enter,  and 
small  particles  of  thrombi,  which  might  form  during  the  softening  of  the 
tumor,  maj'  enter  the  circulation,  become  attached  at  different  places,  and 
form  new  tumors.  In  veins,  the  formation  of  such  thrombi  filled  with  specific 
tumor-elements  has  actually  been  observed,  and,  at  the  same  time,  analogous 
tumors  have  been  found  in  the  branches  of  the  pulmonary  artery.  It  is 
important  to  remember  that  metastatic  tumors,  like  metastatic  abscesses,  are 
chiefly  found  in  the  lungs  and  liver,  except  in  cases  where  direct  metastasis 
is  very  easy,  as  in  pleural  tumors,  which  develop  as  a  result  of  primary  mam- 
mary tumors,  as  in  hepatic  tumors  found  with  those  of  the  intestines  or 
stomach  ;  in  these  cases  a  direct  wandering  of  tissue-elements  through  the 
lymphatic  vessels  is  very  possible.  On  this  point  there  is  still  much  room  for 
investigation,  which,  I  think,  will  meet  great  results.  As  we  have  alread}' 
seen,  the  products  of  acute  inflsimmation  mostly  have  a  {)yrogenous  action  ; 
those  of  chronic  inflammation  lack  this  peculiarity  almost  as  much  as  do 
those  of  tumors  ;  fever  only  occurs  in  the  latter  when  there  is  disintegration 
of  the  neoplasia,  and  the  products  of  the  disintegration  enter  the  circulation  ; 
more  frequently,  infection  with  such  excreted  matters  shows  itself  in  chronic 
inflammation  in  tumors  by  a  general  cachectic  state,  especially  by  disturbance 
of  the  general  nutrition. 


910 


ORAL  DISEASES  AND  SURGERY. 


indeed  very  similar  to  the  section  of  a  fresh  turnip.  Scraping  the 
surface  affords  what  is  commonly  called  the  cancer-juice,  the  micro- 
scopic cell  features  of  which  are  exhibited  in  Fig.  277. 


Fig.  277. 


A  microscopic  view  of  tlie  cells  of  hard  cancer,  showing  their  varictl  shapes,  with  the 
numerous  free  nuclei,  as  seen  in  scirrhus  of  the  breast.  Magnified  5(i()  diameters. 
(After  Paget.) 

It  will  be  seen  from  the  great  variety  of  feature  exhibited  in  these 
cells  that  there  is  here  no  characteristic  cancer-cell.  The  judg- 
ment of  such  growths  is  to  be  founded  on  the  common  heteroclitic 
expression. 


"If  w«  consider  ^vhat  has  been  said  about  the  contagiousness  of  tumors, 
we  see  that  there  is  some  probability  of  their  transfer  from  one  person  to 
another,  though  it  is  not  proved  ;  but  there  can  be  no  doubt  that  the  lymphatic 
glands  and  other  organs  may  be  gradually  infected  by  various  kinds  of  tumors. 

"As  regards  the  effect  of  taking  cold  locally  and  generally  as  a  cause  of 
ihflamniation,  there  are  no  observations  which  would  justify  us  in  referring 
tumors  to  a  similar  cause.  I  do  not  know  that  any  one  has  ever  asserted  and 
proved  that  tumors  result  from  catching  cold. 

"  Views  vary  greatly  about  mechanical  and  chemical  hifluences  as  causes  of 
tumors.  Various  as  the  irritations  may  be,  and  much  as  they  have  been 
experimented  with,  in  no  single  case  has  a  tumor  been  caused  intentionally 
by  mechanical  or  chemical  irritation  ;  inflammatory  new  formations  thus 
developed  do  not  long  outlast  the  external  irritation.  Wherever  and  how- 
ever we  apply  such  mechanical  and  chemical  irritants,  we  only  induce  inflam- 
mations ;  if  there  be  any  specific  mechanical  and  chemical  irritation  (I  mean 
one  acting  on  the  organism  from  without,  not  starting  from  the  tumor),  i.e. 
one  from  whose  action  a  tumor  must  develop,  it  is  at  present  unknown.  Then 
the  question  arises  whether  there  are  any  reasons  which  render  it  absolutely 
necessary  to  assume  such  mechanical  and  chemical  irritation  outside  of  the 
organism.  I  cannot  agree  to  this.  It  is  true  there  are  many  cases  where  a 
tumor  forms  after  a  blow,  Ttick,  or  injury,  but  the  number  of  such  cases  is 
very  small  in  proportion  to  those  where,  after  similar  causes,  there  is  acute 
traumatic  inflammation,  with  a  typical  course,  or,  if  the  irritation  be  con- 
tinued, chronic  inflammation  also  with  typical  course.  We  must  regard  this 
also  as  a  rule :  if  a  porter  gets  a  thickening  of  the  skin,  with  new  mucous 
bursa  under  it,  on  the  spinous  process,  or  if  he  gets  an  ulcer  at  the  same 
point,  it  is  to  some  extent  a  normal  result,  they  are  products  of  a  chronic 


TUMOBS   OF   THE  MOUTH.  911 

The  Sarcomatous  CaScinoma. — This  expression,  from  the  his- 
tological stand-point,  is  to  be  described  as  a  tumor  exhibiting  the 

inflammatory  irritation,  and  disappear  as  soon  as  the  irritation  ceases ;  but  if 
from  the  same  causes  a  person  gets  a  fatty  tumor,  which,  does  not  disappear, 
but  even  continues  to  grow  when  the  irritation  ceases,  we  cannot  here  regard 
the  irritation  as  sijecific,  but  must  seek  the  peculiarity  in  the  atfected  part. 
Previously  in  general  and  local  infections  we  recognized  the  specific  effects  of 
irritation  ;  now  we  must  also  acknowledge  that  there  is  a  specific,  qualitative, 
abnormal  reaction  of  the  tissue.  Virchoio  and  0.  Weber  especially  have 
maintained  that  external  irritation  always  plays  an  important  role  in  the 
development  of  tumors  ;  this  follows  undoubtedly  from  the  fact  that  primary 
tumors  are  most  frequent  at  points  most  subject  to  external  irritation.  Sta- 
tistics show  that  the  most  frequent  seat  of  tumors  is  the  stomach,  then  the 
portio  vaginalis  uteri,  then  the  face  and  lips,  then  the  mammary  glands,  rectum, 
etc.  But  the. reason  for  the  development  of  tumors,  and  not  of  chronic  inflam- 
mation in  such  cases,  must  be  a  specific  disposition  of  these  parts  in  certain 
persons.  Individuals  who  drink  much  spirits  usually  have  gastric  catarrh  ; 
if,  among  one  thousand  topers,  one  or  even  ten,  instead  of  catarrh,  had  cancer 
of  the  stomach,  he  should  be  considered  as  an  abnormal  subject,  when  com- 
pared with  the  mass  who  do  not  have  it.  Up  to  this  poijit  I  agree  entirely 
with  Virchovj,  who  speaks  as  follows:  'Although  I  cannot  tell  in  what  par- 
ticular way  an  irritation  must  occur,  to  induce  a  tumor  in  some  given  case, 
while  in  another  case,  perhaps  under  apparently  similar  circumstances,  it 
merely  excites  simple  inflammation,  still  I  have  communicated  a'  series  of 
facts  which  teach  that,  in  the  anatomical  composition  of  different  parts,  certain 
continuous  disturbances  may  exist  which  interfere  with  the  occurrence  of 
regulating  processes,  and  which,  from  an  irritation  that  at  another  spot  would 
have  induced  a  simple  inflammation,  excite  an  irritation  from  which  the 
specific  tumor  is  developed.'  Among  facts  'which  teach  that,  in  the  anatomical 
composition  of  different  parts,  certain  continuous  disturbances  may  exist' 
which  dispose  to  development  of  tumors,  Virchow  mentions  advanced  age.  It 
is  perfectly  true  that  certain  forms  of  tumors  are  very  frequently  found  on 
particular  parts  of  the  body  in  old  persons,  e.g.  cancer  of  the  lip.  Thiersch 
calls  attention  to  the  fact  that  in  the  lips  of  old  men  the  connective  tissue  is 
often  so  much  atrophied  that  the  epithelial  tissues  (sebaceous,  sweat,  and 
mucous  glands,  hair-follicles,  etc.)  become  very  prominent,  and,  as  it  were, 
receive  the  preponderance  of  nutrition ;  that  hence  irritation  shows  itself 
chiefly  in  the  proliferation  of  these  epithelial  formations,  and  that  this  ex- 
plains the  frequent  occurrence  of  epithelial  cancer  in  the  lips  of  old  men.  I 
fully  recognize  the  shrewd  combination  of  these  observations,  but  I  must  add 
that  advanced  age  is  just  as  much  a  general  as  a  local  peculiarity  of  the  body. 
It  is  also  stated  by  Virchow  that  places  which  have  been  the  seat  of  an  inflam- 
matory disease,  which  has  left  the  part  weakened,  also  cicatrices,  furnish  foci 
for  the  development  of  tumors.  This  is  undoubtedly  true ;  but  if  we  com- 
pare the  innumerable  cases  where  simple  chronic  inflammation  occurs  in 
parts  that  have  been  acutely  diseased,  and  where  simple  ulceration  occurs  in 


912  OBAL  DISEASES  AND   SURGERY. 

features  of  sarcoma  and  carcinoma  in  couibination.  Such  combina- 
tion may  reside  in  degeneration  of  the  sarcoma,  or  may  arise  from  a 

cicatrices,  the  cases  in  which  tumors  occur  at  such  points  appear  very  small, 
and  it  must  be  acknowledged  that  in  these  few  cases  we  may  assume  a  specific 
predisposition  which  leads  to  formation  of  tumors.  The  same  holds  good  for 
the  fact  that  tumors  are  particularly  apt  to  form  in  organs  which  complete 
their  formation  and  development  late  in  life;  here  FtVcAow  classes  the  articu- 
lar ends  of  the  bone  (which,  however,  are  the  seat  of  tumors  much  more 
rarely  than  of  chronic  inflammations),  the  mammary  glands,  the  uterus, 
ovaries,  testicles,  etc.  "While  fully  recognizing  the  exercise  of  observation 
and  brilliant  ideas  by  which  it  is  attempted  to  prove  the  purely  local  disposi- 
tion to  development  of  tumors,  I  cannot  consider  the  proof  as  at  all  con- 
vincing, but  remain  of  the  opinion  ihai  there  is  just  as  onuch  a  specific  predis- 
position to  the  development  of  tumors  as  there  is  to  chronic  infiamm.aiions^  roith 
proliferation  of  the  inflammatory  new  formation,  with  suppuration,  with  caseous 
degeneration,  etc. 

"To  what  has  just  been  said  we  must  add  that  we  cannot  alwaj's  detect  a 
local  external  irritation  when  a  tumor  is  developed,  any  more  than  we  can 
always  do  so  in  local  disease  in  a  scrofulous  patient.  While  referring  you  to 
what  has  been  said  on  the  etiology  of  chronic  inflammations,  I  would  remark 
that  in  regard  to  primary  tumors  we  may  assume  in  many  cases  that  there 
are  also  specific,  so-called  internal  irritations  developing  in  the  body  itself. 
Most  pathtilogists  agree  to  this,  but  they  consider  the  mode  of  origin  and 
development  of  such  irritations  as  being  different.  Virchow  teaches  that  the 
local  disease  must  have  a  local  cause,  and  assumes  that  at  the  point  of  disease 
there  are  certain  local  conditions  of  debility.  If  this  were  so,  we  should 
have  to  assume  a  specific  local  debility  for  the  most  different  disturbances  of 
nutrition  and  for  formation  of  tumors.  Rindjfeisch  speaks  very  decidedly  of 
internal  irritation  as  follows :  '  By  the  change  of  substance  in  the  tissues, 
certain  excretive  substances  are  constantly  being  formed,  which  must  gradu- 
ally be  passed  oft"  from  the  tissues  and  organs  in  which  they  form,  as  well  as 
from  the  fluids  of  the  body  at  large,  in  order  that  the  life  of  the  individual 
may  be  undisturbed.  These  bodies  have  their  chemical  position  between  the 
organopoietic  bodies  on  the  one  hand  and  the  excreted  matter  of  the  kidneys, 
skin,  and  lungs,  on  the  other;  thus  they  fall  into  the  great  gap  that  exists  in 
organic  chemistry  at  this  point ;  they  are  different  for  the  difl'erent  tissues, 
and  on  this  difference  depends  the  variety  of  pathological  new  formations. 
If  they  are  transformed  and  excreted  normally,  they  collect  first  at  the  point 
of  their  origin,  then  in  the  fluids  of  the  body,  and  this  collection  is  the  im- 
mediate cause  for  the  excitement  of  that  progressive  process  which  begins 
with  multiplication  of  cells  in  the  connective  tissue  and  ends  with  the  de- 
velopment of  tubercles,  cancer,  cancroid,  fibroids,  liporaata,  etc'  I  can 
entirely  agree  with  this  hypothesis,  but  must  add  that  it  seems  an  error  to 
suppose  that  we  here  speak  chiefly  of  local  processes.  The  production  of  bile 
and  urine  is  also  a  local  process  ;  for  them  to  be  produced  in  such  quantities 
and  of  such  a  quality  as  they  are  depends  not  only  on  the  glandular  organs, 


TUMORS  OF   THE  MOUTH.  913 

primary  corubination :  this  is  explainable  by  imagining  the  inter- 
stitial   connective   tissues    to    undergo    sarcomatous    degeneration, 

but  on  the  entire  organism  to  such  an  extent  that  we  must  seek  the  original 
causes  of  the  secretion  of  urine  and  bile  not  only  in  the  blood,  but  even  more 
remotely,  even  in  peculiarities  of  origin,  as  far  back  as  Adam,  if  you  please. 
In  the  same  way,  I  think  that  the  original  causes  for  the  local  requirements 
for  the  development  of  tumors  must  be  sought  in  specific  peculiarities  of  the 
individual  organism  ;  in  the  same  way  we  speak  of  a  scrofulous  or  tuberculous 
person,  meaning  the  pathological  race,  as  it  were,  to  which  the  individual 
belongs. 

"  I  must  lasth'  add  that  the  supposition  that  the  cause  of  disease,  the  irrita- 
tion inducing  the  tumor,  develops  locallj',  where  the  tumor  afterward  fcn-ms, 
is  as  purely  hypothetical  as  any  that  has  yet  been  advanced.  Let  us  take 
arthritis  as  an  analogy:  Zaleski  induced  the  most  typical  arthritis  in  a  goose 
by  ligating  the  ureters,  an  articular  disease  resulting  from  disturbance  of 
the  function  of  the  kidneys.  Possibly  tumors  might  just  as  well  develop  in 
any  tissue  from  disturbance  of  the  hepatic  function.  Very  many  things  are 
possible.  We  know  nothing  certain  on  this  point,  and  move  entirely  in 
hypotheses.  For  my  part,  I  find  it  just  as  allowable  to  assume  a  diathesis 
here,  as  in  scrofula,  arthritis,  etc.  ;  that,  partly  from  unknown,  partly  from 
known  causes  of  general  nutrition  and  ordinary  conditions  of  life,  abnormal 
matters  proceed,  which  have  a  specific  irritant  action  on  this  or  that  part  of 
the  body,  analogous  to  that  of  certain  drugs.  Lastly,  if  to  this  we  add  that 
the  diathesis  for  production  of  tumor  is  hereditary,  although  not  to  such  an 
extent  as  the  chronic  inflammatory  diathesis,  the  doctrine  of  weakness  local- 
ized in  certain  systems  of  tissue  or  certain  parts  of  the  body  seems  entirely 
untenable.  There  is  certainly  a  local  cause  for  the  members  of  one  family 
having  large  noses ;  in  proportion  to  the  face,  they  have  grown  larger  than 
in  other  men  ;  still,  the  large  nose  of  the  father  cannot  descend  directly  to  the 
son,  it  can  only  be  inherited  from  the  father  through  the  spermatozoa,  and 
there  the  original  cause  is  to  be  sought;  all  peculiarities  that  descend  by 
inheritance  are  unquestionably  to  be  termed  constitutional. 

"  I  have  now  occupied  you  some  time  with  reflections  which  some  of  you 
may  consider  very  tedious ;  they  will  ask  me,  Of  what  use  are  these  things  in 
practice  ?  Then,  unfortunately,  I  must  acknowledge  that  practice  pays  little 
attention  to  them,  because  they  are  so  hypothetical.  Those  of  you  to  whom 
such  ideas  as  we  have  just  spoken  of  do  not  occur,  I  advise  to  pay  no  further 
attention  to  them  ;  not  to  be  obliged  to  speculate  as  to  the  final  causes  of  things 
is,  in  a  certain  sense,  an  enviable  quality. 

"For  convenience,  let  us  comprise,  in  a  few  short  propositions,  what  we 
have  said  regarding  the  etiology. 

"  Tumors,  like  inflammatory  neoplasise,  result  from  irritation  of  the  tissue  ; 
the  difference  in  the  causes  lies  :  L  In  the  specific  quality  of  the  irritation. 
Infection  of  healthy  tissue  about  a  tumor,  neighboring  lymphatic  glands,  etc., 
is  considered  suflScient  proof  of  this.  It  is  supposed  that,  under  some  un- 
known circumstances,  this  specific  irritant  may  be  formed  locally  {Rindfleisch). 

57 


914  OEAL  DISEASES  AND   SURGERY. 

while  at  the  same  time  the  epithelial  system  of  an  associated  glandu- 
lar organ  would  degenerate  in  like  manner.  A  tumor  of  this  class, 
if  it  recurs  after  removal,  presents  only  the  pure  carcinomatous  ex- 
pression. The  sarcomata  and  carcinomata  are  viewed  by  Koster 
as  very  frequently  having  common  origin  in  a  proliferation  of  the 
endothelium  of  the  lymphatics  of  the  parts  involved. 

Medullary  Carcinoma — Encephaloma. — To  the  mind  of  the 
writer,  encephaloma  expresses  the  very  fullness  of  the  cancerous 

I  think  that,  partly  as  a  result  of  hereditary  predisposition,  partly  from  a 
developed  tendency,  that  is,  where  there  is  a  diathesis,  we  may  imagine  the 
formation  of  materials  in  the  fluids  of  the  body  which  shall  have  a  specific 
irritant  action  on  one  or  other  tissue.  2.  Any,  usually  an  inflammatory, 
irritation  may  excite  a  tumor,  if  the  irritated  tissue  is  specifically  disposed 
for  the  development  of  growths.  Virchow,  0.  Weber,  Rindfleisch,  and  others 
assume  that  such  specific  peculiarities  are  entirely  local  and  limited  to  an 
accidentally  irritated  part  of  the  body,  or  to  a  certain  system  (bones,  skin, 
muscle,  nerves,  etc.).  I  cannot  imagine  the  localization  of  such  specific 
peculiarities;  hence,  even  with  this  hypothesis,  it  seems  probable  that  the 
apparent  local  specific  peculiarities  are  due  to  the  intimate  relations  of  the 
entire  organism. 

"  From  this  representation  you  may  sec  that  the  diflTerent  views  only  differ 
in  the  purely  hypothetical  part.  If  I  entered  into  the  subject  more  fully 
than  seemed  necessary  for  these  lectures,  it  was  because  this  very  important 
branch  of  general  pathology  has  lately  been  so  exhaustively  and  excellently 
treated  of  by  Virchotv,  0.  Weber,  Rindfleisch,  Liicke,  Thiersch^  Plebs,  Waldcyer, 
and  others,  that  I  considered  it  necessary  to  develop  more  fully  those  parts 
of  mj'  views  where  I  differed  from  these  authors,  whose  excellent  writings  I 
cannot  too  strongly  recommend  for  your  study."— ^Billroth. 

"  Carcinoma. — It  is  one  of  the  most  interesting  histological  problems  to 
establish  the  nature  and  the  manner  in  which  primary  carcinoma  effects  the 
infection  of  the  neighboring  lymph-glands,  and  if  that  should  be  proven, 
which  for  the  time  being  is  taken  for  granted,  that  this  is  accomplished  by 
means  of  immigrated  cancer-cells,  to  determine  the  point  at  which  these  cells 
remain  attached,  and  how  they  produce  the  first  nests  of  cancer-cells,  either 
by  their  own  division,  or  by  infecting  the  lymph-corpuscles.  After  numerous 
investigations  directed  to  this  point,  I  can  only  bring  forward  that  the  trans- 
formation of  the  lympluidenoid  substance  into  the  substance  of  a  glandular 
carcinoma  is  accomplished  in  an  exceedingly  simple  manner,  in  that  the 
trabeculte  of  the  reticulum,  like  as  in  chronic  induration,  experience  a  con- 
siderable elongation  and  thickening;  the  meshes  enlarge  from  ten  to  twenty 
times,  and  then,  instead  of  lymph-corpuscles,  contain  the  specific  cancer-cells. 
The  structure  of  the  lymphadenoid  ti.ssue  consequentlj'  appears  to  go  over 
directly  into  the  structure  of  carcinoma,  the  reticulum  into  the  stroma,  the 
lymph-corpuscles  into  the  carcinoma-cells." — Rindfleisch. 


TUMORS  OF  THE  MOUTH.  915 

impression.  It  is  as  a  poison,  which,  either  through  its  own  force, 
or,  what  amounts  to  precisely  the  same  thing,  non-resistance  on 
the  part  of  the  patient,  overwhelms  and  quickly  destroys ;  before  it 
all  tissues  melt  away,  for  none  may  combat  it.  Early  ulceration 
and  the  protrusion  of  fungus  hiematodes  form  the  common  history 
of  encephaloma,  the  cases  being  exceptional  where  a  patient  survives 
over  two  years. 

Pure  encephaloma  of  the  jaws  has,  in  its  inception,  nothing  to 
distinguish  it  from  the  most  simple  of  the  sarcomata;  once  started, 
however,  the  greater  activity  of  the  disease  soon  exhibits  itself, 
showing  the  futility  of  treatment:  particularly  does  this  find  ex- 
pression in  the  infiltrated  appearance  of  all  the  surrounding  parts. 
If  the  idea  of  cutting  has  suggested  itself,  it  is  quickly  enough 
dismissed  by  the  entire  absence  of  any  distinct  line  of  demarkation. 
One  is  made  to  feel  that  in  the  absence  of  a  specific  he  is  powerless 
for  good. 

Encephaloma  does  not  seem  to  the  author  justly  described — cer- 

FiQ.  278. — Ax  Encephalotd  Tumor. 


tainly  not  at  all  so  from  the  clinical  stand-point — when  an  impression 
is  conveyed  of  its  encapsuled  character,  for  never  perhaps  is  it  the 
case  that  inside  of  such  capsule  is  confined  the  heteroclitic  expres- 
sion, cells  differing  from  the  normal  tissue  being  found  infiltrated 


916 


ORAL  DISEASES  AND  SURGERY. 


not  only  throughout  the  substance  of  such  capsule,  but  also  in  all 
the  neighboring  parts. 

Fig.  279. — An  Encephaloid  Expression  of  Cancep.  in  a  Young  Child. 


Section  of  an  encephaloid  tumor,  as  is  to  be  inferred,  presents 
varying  expression:  it  is  sometimes  quite  brain-like,  or  it  may,  as  it 
shades  into  less  malignancy,  simulate  scirrhus :  occasionally  it  will 


Fig.  280. 


Fig.  281. 


Fig.  282. 


*;pS«^^^ 


Fig.  280.  A  microscopic  view  of  the  nuclei  of  soft  medullary  carcinoma  imliedded  in  a 
molecular  basis  substance  or  stroma  without  cancer-cells.  Magnified  500  diameters.  (After 
Paget.) 

Fig.  281.  A  representation  of  various  fully-developed  cells  and  nuclei  of  medullary 
carcinoma,  as  seen  under  the  microscope.  Magnified  500  diameters.  Some  of  them  are 
larger  than  the  average,  others  more  peculiarly  slender,  elongated,  strip-like,  or  caudate 
cells,  with  darkly-dotted  granular  nuclei.  (After  Paget.) 

Fig.  282.  A  representation  of  the  dotted  nuclei  of  medullary  carcinoma  of  the  breast. 
Magnified  500  diameters.  (After  Paget.) 


TUMORS   OF   THE  MOUTH. 


917 


Fig.  283 


Fig.  284. 


Fig.  283.  A  representation  of  the  clustered  nuclei  of  nieihillary  cancer,  composed  almost 
exclusively  of  round,  shaded  nuclei,  with  three  or  four  shining  particles,  arranged  in 
groups  or  clusters  of  five  to  twenty  or  more.  Magnified  about  400  diameters.  (After 
Paget.) 

Fig.  284.  A  representation  of  the  caudate  and  variously  elongated  cells  of  a  firm  medul- 
lary cancer.    Magnified  450  diameters.  (After  Paget.) 

Fig.  28.5.  Small  elongated  cells  and  nuclei  with  a  nucleus  of  the  ordinary  shape,  from  a 
firm  medullary  cancer.    Magnified  500  diameters.  (After  Paget.) 

be  colored,  such  coloring  being  the  pigment-granules  of  raelanosis,- 
melanoid  cancer.* 


*  The  student  who  is  observant  of  the  histological  expressions  of  tumors 
will  be  much  interested  in  the  work  now  being  done  in  the  Surgeon-General's 
Department  at  Washington,  and  in  the  promise  by  the  eminent  microscopisl, 
Dr.  J.  J.  Woodward,  of  a  series  of  illustrated  papers.  Of  these  papers, 
a  first  has  just  been  received  by  the  author ;  the  illustrations,  being  micro- 
photographic,  necessarily  insure  perfect  confidence  in  their  absolute  correct- 
ness. 


CHAPTER    XLIY. 


EPITHELIOMA, 


Not  admitting  that  epithelial  degeneration  is  necessarily  any  more 
an  expression  of  the  cancer  vice  than  is  the  degenerated  interstitial 
cellular  tissue  of  the  fibro- sarcomata,  we  come  now  practically  to 
demonstrate  the  truth  of  the  conclusion,  by  treating  of  an  order  of 
cases  all  of  which  are  epithelial  diseases,  but  not  all  of  which  are 
cancer. 

At  the  clinics  of  every  hospital  surgeon  are  constantly  presenting 
cases  of  tumors  or  ulcerations  associated  with  the  skin  or  mucous 
membrane,  to  which  are  applied  the  common  name  of  epithe- 
lioma :  these  conditions  differ  very  much  in  appearance.  When  it 
commences  in  the  skin,  the  disease  is  apt  to  present  itself  in  the 
warty  or  indurated  form ;  when  on  clear  mucous  membrane,  as  an 
ulcer.  Situated  upon  the  lip  or  anus,  having  thereby  association- 
with  both  skin  and  mucous  membrane,  it  may  present  itself  in  either 
form,  or  even  be  pedunculated. 

Fig.  287. 


Fig.  233. — Ixduratkd  Epi- 
thelioma. 


Fig.  286,  being  a  case  from  "life,  represents  an  indurated  epithe- 
lioma.    Fig.  287,  also  from  life,  represents  the  ulcerated  variety. 
Theepitheliomata  receive  the  best  clinical  judgment  when  viewed 
(918) 


EPITHELIOMA. 


919 


precisely  as  we  have  studied  tumors;  that  is,  as  self-explaining  and 
non-explaining  conditions.  A  common  wart,  implicating  as  it  does 
in  the  papillary  hypertrophy  the  associated  epiderm,  is  to  such 
extent  an  epithelioma.  An  abrading  ulcer,  whether  the  result  of 
local  or  constitutional  accident,  is  made  to  come  under  the  common 
appellation. 

Epithelial  degenerations,  the  result  of  no  explainable  cause,  are, 
unfortunatel}^,  very  frequent,  and  these  degenerations  have  come  to 
be  esteemed  typical  of  cancer ;  the  various  progress,  however,  and 
conditions  of  such  disease  show  plainly  enough  that  it  is  not  the 
seat  of  the  disease,  but  the  disease  itself,  that  we  are  to  appreciate. 

Epithelial  abrasions  from  jagged  teeth,  or  from  the  continuous 
irritation  of  a  pipe-stem,  or  the  clasp  of  an  eye-glass  ;  from  the  con- 
tact of  filth,  as  exhibited  in  the  chimney-sweep  ;  from  long-continued 
pressure  upon  a  part ;  from  wounds,  etc.,  are  common  enough  ;  yet 
few  of  them,  comparatively,  if  judiciously  treated,  are  found  to  prove 
permanently  hurtful. 

On    the    other   hand,  epithelial   degenerations  having  primarily 
the    most   insignificant   expression   progress  to  the   destruction  of 
all  neighboring  parts  and  the  life  of  the 
patient.     Fig.  288,  being  from  life,  and 
having  the  following  history,  may  be 
presented  as  an  illustration. 

Case  I. — Epithelioma  of  Gum, — 
M.  G.,  aged  about  twenty-one,  farmer  by 
occupation,  was  sent  to  me  about  two 
years  back  by  Dr.  Edward  Townsend, 
whose  dental  patient  he  was.  Dr.  T., 
while  treating  a  bicuspid  tooth,  remarked 
at  the  neck  a  slight  ulceration,  but  which, 
appearing  of  little  consequence,  scarcely 
at  the  time  commanded  more  than  a  pass- 
ing-thought.   Attempting,  however,  at  a 

later  period,  a  cure,  its  obstinacy  in  yielding  excited  his  suspicions, 
and,  being  unwilling  to  assume  the  trouble  of  the  case,  he  directed 
the  patient  to  my  care.  Examination  made  on  first  meeting  the 
patient  revealed  a  small  ulcer  on  the  left  superior  gum  between  the 
bicuspid  teeth,  in  size  about  half  as  large  as  the  silver  three-cent 
piece,  jagged,  covered  with  a  whitish  gummy  secretion,  and  appa- 
rently superficial.  The  passage  of  a  sharp  probe  through  the  centre 
of  the  ulcer  revealed   carious,  softened,  and  periosteally  denuded 


Fig.  288.— View  of  Case 
a.s  first  seen. 


920  ORAL  DISEASES  AND  SURGERY. 

bone.  Impressed  with  the  character  of  the  ulceration,  yet  unwilling- 
while  there  might  be  an  unrefuted  doubt,  however  slight,  to  depress 
the  patient  by  informing  him  of  the  nature  of  his  disease,  he  was 
placed  under  ordinary  treatment  for  a  period  of  two  weeks,  at  the 
end  of  which  time,  finding  the  experience  in  treatment  to  agree  with 
that  of  Dr.  Townsend,  his  condition  was  laid  before  him,  immediate 
resection  of  the  affected  and  adjoining  parts  being  advised.  Unwill- 
ing to  submit,  the  patient  desired  consultation,  and  in  turn  the  advice 
of  every  prominent  surgeon  in  the  city  was  obtained.  Opinions 
differing,  he,  by  advice,  submitted  him.self  to  various  proposed  reme- 
dies, being  treated  two  weeks  by  one  gentleman,  eight  weeks  by  a 
second,  and  nine  by  a  third,  the  disease  progressing,  though  slowly, 
all  these  weeks.  At  the  end  of  this  time,  operation  was  again  proposed 
and  insisted  upon,  the  patient  being  informed  of  the  necessarily  in- 
creased magnitude  of  the  portion  of  bone  and  soft  parts  to  be  removed; 
upon  his  still  refusing,  further  responsibility  in  the  case  was  declined. 
The  patient  making  the  author  a  visit  at  a  later  period,  the  ulceration 
was  found  involving  the  Stenonian  duct  and  extending  from  the 
symphysis  to  the  tuberosity  of  the  bone.  At  this  visit  he  was  in- 
formed of  the  utter  hopelessness  of  any  operation  for  his  relief,  the 
disease  being  too  extensive.  From  this  time  until  his  death,  which 
happened  in  a  few  months,  he  was  in  the  hands  of  different  adver- 
tising impostors.  Whether  or  not  an  early  operation  would  have 
saved  this  patient  from  his  early  death  one  may  not  of  a  certainty 
say,  but  from  a  reasonable  experience  in  the  direction,  it  may  be 
asserted  that  without  the  performance  of  such  proposed  operation 
he  had  no  possible  chance. 

The  frequency  with  which  the  isolated  syphilitic  epitheliomata 
have  been  mistaken  and  treated  for  cancroid  of  cancerous  expression, 
is  known  to  every  surgeon  whose  opportunities  bring  him  much  in 
consultation,  while,  on  the  other  hand,  it  has  happened  directly 
to  the  author  to  see  at  least  a  hundred  cases  of  the  malignant 
or  non-explaining  condition  mistaken  for  sores  of  a  simple  local 
signification.* 

*  A  vertical  section  of  an  ordinary  epithelioma  shows,  at  the  upper  border, 
a  scab ;  if  this  be  detached,  a  whitish  slough-like  layer,  consisting  of  loosely 
aggregated  epithelial  scales,  which  have  been  detached  from  the  deeper  struc- 
tures, and  which  may  be  readily  removed  by  washing.  The  main  substance 
of  the  growth  has  commonlj-a  somewhat  shining  grayish-white  hue,  is  close- 
textured,  firm,  and  rather  elastic,  and  occasionally  presents  a  striped  appear- 
ance, due  to  its  papillary  structure.    Squeezing  or  scraping  brings  out  a  curdy, 


EPITHELIOMA.  921 

Called  to  the  examination  of  epithelial  derangement,  the  practi- 
tioner may  only  most  rationally  seek  to  explain  the  condition  in  the 
discovery  of  a  cause.  Not  that  in  the  absence  of  such  cause  the 
condition  is  necessarily  to  be  found  destructive ;  such  absence  may  be 
only  apparent,  the  oversight  lying  in  the  inability  of  the  surgeon  to 
perceive  a  cause  which  might  be  evident  enough  to  closer  and  truer 
observation.  Case  II.,  of  which  Fig.  286,  from  life,  is  an  illustration, 
may  be  offered : 

Mr.  X.,  carpenter  by  occupation,  was  sent  to  the  author  laboring 
under  an  indurated  tumefaction  involving  a  full  half  of  the  inferior 
lip:  the  tumor  was  semi-bluish,  slightly  lobulated,  and  painful,  had 
existed  for  over  a  year,  was  gradually  enlarging  and  softening.  The 
diagnosis  of  epithelioma  but  verified  the  opinion  of  several  other 
practitioners  who  from  time  to  time  had  examined  it.  Recommended 
the  removal  of  the  whole  lip,  which  was  concurred  in  by  the  patient. 
The  gap,  which  was  made  in  the  ordinary  V-shape,  great  as  it  was, 
being  carried  from  either  angle  of  the  mouth  to  the  symphysis  menti, 

yellowish-white  material,  which  resembles  the  comedones,  or  sebaceous  con- 
tents of  hair- follicles,  and  which,  according  to  Paget,  unlike  "cancer-juice," 
does  not  readily  become  equally  diffused  when  mixed  with  water.  This  dis- 
tinction is,  however,  wanting  in  the  very  soft  epitheliomata.  Epithelioma 
is  infiltrated  into  the  tissue  in  which  it  occurs,  and  the  normal  structure  can 
therefore  often  be  traced  into  the  epitheliomatous  mass. 

Under  the  microscope,  the  characteristic  structures  of  epitheliomata  are 
found  to  consist  of  (1)  cells,  which  are  nucleated,  flattened,  and  scale-like, 
much  resembling  the  ordinary  epithelial  cells  (whence  the  name  of  the  dis- 
ease), from  jJjj  to  jji^  (usually  ^i^)  of  an  inch  in  diameter,  and  containing 
a  few  granules,  and  a  clear,  round  or  oval,  well-defined  nucleus  (about  3^3^00  ^*^ 
an  inch  in  diameter),  which  itself  contains  granules,  but  rarely  a  distinct 
nucleolus  ;  these  cells  assume  very  various  forms,  being  sometimes  wrinkled, 
caudate,  or  elongated,  sometimes  without  nuclei,  and  sometimes  filled  with 
oily  particles,  as  if  from  fatty  degeneration  ;  (2)  nuclei,  free  or  imbedded, 
most  abundant  in  the  most  acute  cases,  sometimes,  like  the  nuclei,  seen  in  the 
epitheliomatous  cells,  but  sometimes  larger,  with  more  distinct  nucleoli,  and 
much  resembling  the  nuclei  of  scirrhus  or  medullary  cancer  ;  (3)  brood-cells, 
or  cells  containing  nuclei  undergoing  development  into  nucleated  cells,  the  suc- 
cessive formation  of  one  cell  within  another  sometimes  giving  a  peculiar  lami- 
nated appearance ;  and  (4)  laminated  capsules,  nests,  or  epidermic  or  concentric 
globes,  consisting  of  concentric  layers  of  epithelial  scales,  containing  in  the 
central  space  granular  or  oily  matter,  cells,  or  free  nuclei,  and  apparently 
resulting  from  a  continuation  of  the  process  of  endogenous  cell  formation,  de- 
scribed as  giving  a  laminated  appearance  to  the  simpler  brood-colls.  These 
nests,  or  concentric  globes,  are  met  with  in  other  epidermic  formations,  but 
are  better  marked  in  epitheliomatous  than  in  any  other  structures. — Ashhurst, 


922  ORAL  DISEASES  AND  SURGERY. 

was  filled  up  without  any  considerable  effort  by  forcing  the  cheeks 
toward  the  mesial  line,  retaining  them  in  position  by  an  extempo- 
rized Dewar's  compressor,  and  appi'oximatingthe  edges  of  the  wound 
with  the  hare-lip  pin  and  suture.  The  wound  united  happily  by 
first  intention  throughout,  and  although  at  first  the  stretched  tyissues 
bound  the  lower  jaw  so  closely  as  almost  to  prevent  the  patient  from 
opening  the  mouth,  yet  in  three  months  after  the  operation  the  parts 
bad  accommodated  themselves  so  completely  to  the  new  condition 
of  things  that  one  would  almost  failto  detect  that  the  natural  parts 
had  ever  been  interfered  with.  The  success  of  the  treatment  was 
all  that  could  be  desired  ;  nearly  seven  years  have  passed,  and  there 
is  not  the  slightest  evidence  of  a  return  of  the  trouble. 

A  case  illustrative  of  the  opposite  aspect — that  is,  where  a  local 
cause  is  plainly  evident,  yet  destruction  to  life  is  the  result — is 
shown  in  Fig.  281,  also  taken  from  life: 

Case  III. — Col.  W.,  merchant.  Epithelioma  involving,  when  first 
seen,  lip,  tongue,  and  cheeks, — case  hopeless.  The  disease  in  this 
patient  began  as  a  minute  tubercle  just  over  the  genial  bodies  of  the 
inferior  maxilla;  little  was  thought  about  it,  and  it  only  received  at- 
tention when  found  ulcerating,  such  attention  consisting  in  the  appli- 
cation of  caustics.  Aggravated  J)y  such  treatment,  the  ulceration  com- 
menced rapidly  to  spread,  defying,  when  too  late  understood,  every 
means  employed  for  its  arrest.  Shortly  after  coming  under  care,  the 
lip  fell  off  in  mass,  the  root  of  the  tongue  became  indurated  to  such  an 
extent  as  to  interfere  with  both  respiration  and  deglutition,  and  the 
patient,  a  fine  robust  man,  died  from  prostration.  In  this  instance 
the  patient  for  many  years  had  been  in  the  habit  of  holding  the  tip 
of  bis  cigar  between  the  tongue  and  floor  of  the  mouth.  ]Many 
persons,  however,  so  hold  cigars  without  cancerous  disease  result- 
ing. In  such  cases,  however,  no  tendency  of  the  kind  in  the  system 
exists  to  be  localized. 

Epithelioma  of  simple  traumatic  signification  is  distinguishable 
from  the  cancerous  specific  in  the  nature  of  the  sore,  looking,  if  not 
too  much  fretted,  like  a  healthy  ulcer,  that  is,  being  of  a  pinkish-red, 
smoothly  regular,  granulated  face. 

Epithelioma  of  syphilitic  expression  differs  not  only  from  the 
malignant,  but  also  from  the  traumatic,  in  having  a  paste-  or  film- 
covered  bottom. 

Epithelioma  of  cancerous  type  is  distinguishable  from  the  preced- 
ing classes  of  ulcers  in  presenting  giant  granulations,  a  fit^sured 
surface,  and  most  irregular  and  ragged  edges. 


EPITHELIOMA.  903 

The  most  common  seat  of  epithelial  degeneration  is  the  lower 
lip ;  after  this,  the  tongue  ;  the  inside  of  the  cheeks  is  also  a  very 
frequent  seat  of  the  disease.     (See  Diseases  of  Tongue.*) 

As  most  commonly  met  with  upon  the  lip,  the  condition  makes  its 
appearance  as  a  simple  crack  or  fissure, — a  sore  generally  of  such 
insignificant  appearance  and  inconvenience  as  to  obtain  for  a  long 
period  neither  attention  nor  treatment.  Aroused,  however,  sooner  or 
later,  into  activity,  its  progress  is  rapid  or  otherwise,  according  to 
circumstances  which  influence  it.  (See  Tumors.f)  The  moment  such 


*  For  the  epitheliomata  of  the  lip,  Hutchinson  proposes  the  name  "  ulcus 
rodens,"  denying  it  a  cancerous  signification,  and  desiring  to  class  it  among 
the  non-specific  chronic  inflammations. 

J  In  the  truly  practical  and  learned  work,  by  Prof.  H.  H.  Smith,  on  Sur- 
gery, occur  the  following  passages,  which  may  only  bo  read  by  a  student  to 
his  profound  advantage : 

"  When,  from  anj'  cause,  irritation  is  developed  in  the  skin,  its  appendages, 
or  in  the  rnucous  membranes,  the  normal  action  that  daily  casts  oflT  dead  epi- 
thelial cells  is  increased,  and  may  be  followed  by  hypertrophy,  or  by  such 
thickening,  degeneration,  and  ulcerative  action  as  will  materially  modify  the 
normal  condition.  Tumors  thus  formed  on  the  skin  and  mucous  membrane 
by  the  accumulation  of  a  largelj'-increased  number  of  epidermic  and  epithelial 
cells,  united  together  by  filaments  of  fibrous  tissue,  and  furnished  with  blood- 
vessels, as  the  result  of  the  organization  of  the  fibrinous  deposit,  have  been 
called,  by  Hannover,  epithelioma. 

"  Epithelioma  varj^  considerably  in  ajipearance.  If  the  result  of  the  irrita- 
tion caused  bj'  pressure  on  the  skin,  they  constitute  corns  of  common  language, 
and  are  a  true  hypertrophy  of  the  epidermis.  "When  the  epidermic  cells  are 
closely  packed  together  by  pressure,  they  create  hard  corns  5  when  the  cells 
are  more  distinct  and  disposed  to  a  papillary  arrangement,  owing  to  the  pres- 
ence of  a  greater  amount  of  moisture,  they  form  soft  corns. 

"  When  the  epidermic  cells  accumulate  upon  a  surface  in  consequence  of 
the  increased  action  that  follows  a  local  congestion  or  simple  redness,  they 
form  the  varieties  of  skin  disease  known  as  the  squamaj  or  scaly  class,  as 
psoriasis.  Condylomata  and  venereal  warts  are  analogous  tumors,  usually 
found  on  the  points  where  the  skin  and  mucous  membranes  blend,  as  the  corona 
glandis  of  the  penis,  the  vulva  and  anus,  or  about  the  lips  and  nostril.  Both 
venereal  warts  and  condylomata  are  developed  apparently  in  some  instances 
in  consequence  of  a  peculiar  contamination.  When  closely  examined,  condylo- 
mata are  found  to  be  formed  of  a  congeries  of  papillae,  sometimes  flattened  on 
the  top,  while  others  have  fissures  that  lead  down  to  a  common  stalk.  When 
small,  condylomata  are  mostly  composed  of  epithelial  scales,  but  in  the  larger 
growths  there  is  more  or  less  areolar  tissue  supplied  with  small  blood-vessels. 
A  vertical  section  exhibits  a  vascular  loop  surrounded  by  a  basement  mem- 


924  ORAL  DISEASES  AND  SURGERY. 

a  sore  commences  to  throw  out  exuberant  granulations,  no  hesitation 
is  to  be  felt  in  effectinar  the  most  radical  removal. 


brano,  external  to  which  are  layers  of  epithelial  cells  that  vary  in  thickness.* 
Common  skin  warts,  as  often  seen  on  the  hands,  belong  strictly  to  the  class 
of  epithelioma,  being  formed  of  epithelial  cells  not  compressed,  and  of  a  papil- 
lary form.  These  are  mainly  the  result  of  some  local  irritant  that  increases, 
on  a  circumscribed  spot,  the  epidermic  cell-action.  All  these  tumors,  when 
inflamed,  may  undergo  fatty  degeneration,  softening,  and  ulceration,  creating 
ichorous  and  irritating  discharges,  and  sympathetic  irritation  of  adjacent 
lymphatic  glands,  those  of  the  groin  occasionally  enlarging  from  irritated 
corns  on  the  toes,  and  those  of  the  axilla  from  inflamed  warts  on  the  fingers. 

"  The  greater  vascularity  of  mucous  membranes  modifies  the  formation  of 
epithelioma  in  this  tissue,  the  induration  or  small  scaly  wart  degenerating 
and  ulcerating,  and  creating,  through  inflammatory  action,  more  or  less  indu- 
ration of  the  parts  immediately  adjacent. 

"  When  any  irritation  develops  this  action  on  a  mucous  membrane,  or 
where  mucous  tissue  and  skin  blend,  it  is  apt  to  create  an  ulcerated  epithelioma 
that  is  ditficult  to  heal.  This  variety  is  found  on  the  margin  of  the  lip,  in  the 
aljc  of  the  nostril,  in  the  inner  canthus  of  the  eye,  after  fissure  of  the  nipple, 
on  the  tip  and  margin  of  the  tongue,  on  the  os  uteri,  as  well  as  on  the  vulva, 
prepuce,  and  anus.  The  i-odent  skin  ulcer  of  the  scrotum  and  lupus  are  also 
assigned  to  this  same  class  of  growths.  When  in  these  localities  epithelioma 
is  developed,  it  commences  as  a  flattened  induration  or  scale,  which  is  followed 
by  a  slight  crack  or  fissure,  and  an  ichorous,  watery  exudation  that  is  irritating. 
Hence  increased  action,  then  ulceration,  with  induration  of  the  margin, 
so  as  to  give  an  apparent  depth  to  the  ulcer,  which  is  in  reality  quite  super- 
ficial. The  pus  from  this  ulcer,  being  small  in  quantity,  soon  dries,  and  forms 
a  scab  or  scale,  which,  being  accidentally  removed,  is  followed  by  slight 
bleeding  and  another  crust,  the  reproduction  being  in  this  manner  continued 
for  months.  When  these  ulcers  are  examined  microscopically,  they  present 
on  the  surface  masses  of  epithelial  cells  in  all  stages  of  development.  The 
lymphatic  glands  near  these  ulcers  often  enlarge,  and  are  secondarily  alfected, 
in  consequence  of  which  many  writers  regard  this  variety  of  epithelioma  as 
analogous  to  cancer.  That  epithelioma  may  assume  the  cancerous  peculiari- 
ties under  some  circumstances,  is  beyond  question  ;  but  it  is  equally  certain 
that  it  is  erroneous  to  regard  all  epithelioma  as  cancerous,  some  of  the  cases 
being  onlj' evidence  of  disordered  epjidermic  and  epithelial  cell-action,  and 
capable  of  perfect  cure. 

"  The  opinions  of  pathologists  on  the  identity  of  epithelioma  and  cancer 
are,  however,  yet  much  divided, — Paget,  Velpeau,  and  Schuh  regarding  it  as 
cancer,  and  calling  it  epithelial  cancer,  while  Lebert,  Hannover,  Bennet,  and 
Lawrence  deny  its  cancerous  nature.*    Lawrence  thus  arranges  the  arguments : 


*  Bennet's  Lectures  ;  and  Lawrence  on  Cancer,  1858. 


EPITHELIOMA.  995 

Appearing  upon  the  mucous  surface  of  the  cheek,  anxiety  may 
always  be  felt  for  the  result.  The  expression  is  here  always  more 
or  less  that  of  infiltration,  and  how  best  to  treat  the  condition  is  a 
question  which  repeats  itself  in  every  individual  case. 

Appearing  upon  the  skin,  epithelioma  may  be  esteemed  of  least 
formidable  import. 

Between  the  epitheliomata  there  are,  as  has  been  suggested,  the 
most  decided  differences  in  expression,  a  matter  which  has  been 
studied  with  most  clearness  by  Thiersch  and  Koster.  Many  cases 
are  found  to  remain  quite  superficial,  being  strictly  external  to  the 
subcutaneous  cellular  tissue ;  these  have  received  the  appellation 
of  the  flat  variety.  In  this  form  the  author  would  particularly  call 
attention  to  the  great  benefit  to  be  found  in  moderate  and  continuous 
pressure :  indeed,  if  the  granulations  be  first  sloughed  away  with  a 

"  I. — Foi-  Epithelioma  being  Cancer. 

"1.  Its  infiltrating  character. 

"  2.  Its  tendency  to  infect  the  lymphatic  glands. 

"  3.  Its  tendency  to  recur  after  removal. 

"4.  Its  fatality. 

"  II. — Epithelioma  is  not  Cancer. 

"1.  From  the  excessively  rare  occurrence  of  consecutive  deposits. 

"  2.  Its  anatomical  structure. 

"  3.  The  absence  of  primary  cachexia. 

"  4.  Its  frequently  local  origin. 

"  A  careful  study  of  the  question,  seconded  by  some  experience,  induces  me 
to  regard  the  question  as  thus  correctly  stated  : 

"  1st.  Epithelioma  exists  as  a  distinct  growth,  characterized  by  epithelial 
cells,  as  in  corns,  thickened  skin,  horns,  warts,  etc. 

"  2d.  These  may  become  the  seat  of  cancerous  action,  and  run  the  course  of 
cancer  to  degeneration,  though  in  the  least  marked  form,  being  then  well 
designated  as  'cancroid.' 

"  3d.  There  is  a  cancer  of  the  skin  and  mucous  membranes,  originating  in 
the  follicles,  that  presents  the  usual  elements  of  cancerous  action  elsewhere, 
which  yet  presents  epithelial  cells,  and  the  other  normal  elements  of  the 
tissue  invaded. 

"  4th.  Simple  epithelioma  is  to  be  regarded  as  really  a  hypertrophy  which, 
when  inflamed  or  irritated,  ulcerates  and  undergoes  the  usual  changes  of 
healthy  inflammation. 

"When,  as  is  sometimes  seen,  a  sebaceous  follicle  participates  in  the  in- 
creased epidermic  cell-action  of  epithelioma,  it  results  in  a  thickened  growth 
that  is  so  indurated  as  to  be  called  a  horn.  Some  of  the  instances  of  this 
development,  and  especially  one  well  known  to  visitors  in  Paris,  on  the  fore- 
head of  a  woman,  have  attained  several  inches  in  length. 


926  ORAL  DISEASES  AND  SURGERY. 

caustic  of  chloride  of  zinc,  and*  after  the  separation  of  the  slough 
the  compress  be  applied,  the  cases  are  exceptional  where  cicatrization 
may  not  be  secured.  This  result  has  been  again  and  again  demon- 
strated at  the  University  hospital  clinic. 

A  second  form,  that  alluded  to  as  being  most  common  to  the 
cheek,  the  infiltrated  variety,  enters  the  tissues  deeply,  and  is  thereby 
rendered  the  less  susceptible  to  external  means ;  this  is  the  disease 
in  its  worst  expression. 

A  third  form,  the  villous,  is  most  frequently  found  of  direct  papil- 
lary signification,  and  may  be  treated  by  extirpation  with  reasonable 
hopes  of  a  non-return. 

Epithelial  growths,  as  suggested  by  Billroth,  "gland-like  in- 
growths, "  might  be  inferred  not  unfrequently  to  grow  into  the  spaces 
between  the  connective-tissue  bundles,  where  lymph  circulates,  for 
there  tlie  tissue  offers  least  resistance.  These  are  the  tubes  and 
cylinders  which  Koster  thinks  he  has  proved  "lie  solely  in  the 
lymphatic  vessels." 

The  epithelial  pearls,  described  by  the  histologist,  are  a  result  of 
a  glol)ular  union  of  cells  of  the  flat  variety  ;  their  development  being, 
most  likely,  as  has  been  suggested  by  BiUroth,  from  the  increasing 
division  of  a  number  of  conglomerate  cells,  the  peripheral  layer  being 
flattened  by  pres.sure  against  the  parts  around,  which  are  not  very 
distensible. 

Concerning  the  question  of  malignancy  or  non-malignancy  of  the 
epitheliomata,  no  more  question  would  seem  to  exist  than  in  the 
case  of  tumors  or  ulcers  elsewhere  ;  indeed,  it  seems  to  be  a  self- 
demonstrating  fact  that  the  cancer  vice — accepting  the  humoral 
theory — has  the  most  decided  predilection  for  this  tissue  ;  so  has  also 
the  syphilitic,  but  this  does  not  imply  that  every  ulcer  met  with 
upon  an  epithelial  surface  is  either  venereal  or  cancerous.  A  first 
question,  then,  always,  is  to  be  of  the  character  of  the  tumor  or  ulcer. 
(See  Si/philitic  Ulcers  of  Gums  and  of  Tongue.) 

Epitheliomata  of  cancerous  character  are  more  common  to  men 
than  to  women,  and  are  rarely  found  to  make  their  appearance  about 
the  mouth  before  the  fortieth  year  ;  upon  the  skin,  although  closely 
restricted  to  advanced  adult  life,  they  are  yet  to  be  met  with  even  in 
the  quite  young.  The  author  has  treated  a  number  of  cases  where 
the  patients  were  not  over  twenty-three. 

The  treatment  of  the  epitheliomata,  as  will  be  inferred  from  what 
has  been  written,  considers  the  indications  of  each  particular  case 
as  it  may  be  understood  :  thus,  an  ulcer  from  a  wound  is  to  have  the 


EPITHELIOMA.  927 

treatment  of  a  wound  ;  if  it  be  of  venereal  expression,  remedies 
directed  to  that  vice  are  to  be  employed.  Cancerous  epitheliomata 
are  either  to  be  soothed  and  held  in  abeyance,  or  treated  by  the 
most  radical  operations. 

Whether  the  radical  treatment  by  excision  or  by  the  use  of  caustics 
is  to  have  preference,  would  seem  to  reside  with  the  question 
of  location.  Where  the  disease  is  strictly  localized,  as  seen  in  the 
early  stage  of  lip-cancer,  then  excision,  always  to  be  made  wide  and 
free,  is  to  have  preference.  In  the  infiltrated  variety,  on  the  contrary, 
if  attempt  at  removal  seems  permissible,  it  is  the  experience  of  the 
writer  that  the  caustics  are  to  be  used  :  trifling,  however,  is  the 
promise  from  any  means. 

Of  caustics  so  used,  none  may  have  precedence  of  the  chloride  of 
zinc,  and  this  is  to  be  used  in  its  purest  form.  A  cauterization,  to 
be  of  service,  must  be  thorough  ;  anything  less  than  killing  a  part 
outright  will  always  be  found  productive  of  far  more  harm  than  good. 
Of  the  various  substances  and  means  that  from  time  to  time  have 
been  used  and  applauded,  may  be  mentioned  the  Vienna  paste,  nitric 
and  hydrochloric  acid,  arsenic,  monochloracetic  acid  (Atkinson),  elec- 
trolysis (Neftel),  strangulation,  Landolfi's  caustic,  Mance's  paste. 
What  particular  destructive  shall  be  used  amounts,  however,  to  little 
in  the  way  of  preference :  to  kill  the  parts  outright  is  the  indication, 

A  practice  most  frequently  and  most- satisfactorily  pursued  by  the 
author  in  this  direction,  consists  in  covering  the  part  to  be  acted  on 
with  the  undeliquesced  crystals  of  the  chloride  of  zinc,  corroding 
away,  by  the  imuiediate  repetition  of  this  agent,  the  parts,  until  the 
diseased  scales  are  all  destroyed  ;  the  eschar  thus  produced  is  treated 
like  any  other  sloughing  wound.  When  the  slough  conies  away,  if 
it  be  possible,  compression  is  employed. 

Treatment  by  injection  of  bromine  is  commended  by  Dr.  Wynn 
Williams ;  a  patient  exhibited  by  this  practitioner  to  the  Obstetrical 
Society  of  London,  was  a  person  nearly  the  whole  of  whose  lower 
lip  had  been  removed  for  epithelioma  eighteen  months  previously. 
The  disease  shortly  appearing  in  the  cicatrix,  the  growth  was  suc- 
cessfully treated  by  two  injections  of  bromine,  twenty  drops  to  a 
drachm  of  spirit.  There  was  no  appearance  of  any  return  of  the 
disease. 

Injections  of  glacial  acetic  acid  and  of  Monsel's  solutions  of  iron, 
both  of  which  have  been  liighly  recommended,  have  been  submitted 
by  the  author  to  the  most  exhaustive  tests.  No  good  results,  however, 
have  ensued. 


928  ORAL  DISEASES  AND  SURGERY 

Treatment  by  the  knife  consists  in  complete  ablation  of  the  dis- 
eased mass.  Unless  an  extirpation  may  be  thorough,  there  is  no  excuse 
for  attempting  such  mode  of  treatment.  For  the  study  of  the  opera- 
tions about  the  mouth  and  face,  see  the  chapters  on  these  subjects, 
also  the  chapter  on  Diseases  of  the  Tongue. 

In  the  numberless  cases  of  epithelioma  where  the  most  superficial 
observer  would  recognize  the  impropriety  of  attempt  at  cure  by 
operation,  it  becomes  a  necessity  to  support  the  strength  and  con- 
tribute to  the  local  comfort  of  the  patient.  Here  medicines  which 
are  found  most  antagonistic  to  the  disease  are  by  all  means  indicated. 
Of  such  local  means  the  author  would  most  highly  recommend  the 
daily  use,  by  means  of  an  atomizer,  of  the  following  combination  : 

R. — Acidi  carbolici,  5.) ; 
Sodae  sulphitis,  5j ; 
Aquae,  ^x.     M. 

Not  only  will  this  preparation  be  found  to  afford  much  relief  from 
pain,  and  to  be  softening  and  soothing,  but  it  has  seemed  to  possess 
marked  influence  in  retarding  the  progress  of  the  disease.  It  may  also 
be  administered  internally  in  teaspoonful  doses.  The  American  drug 
hydrastis  canadensis,  used  in  lotion,  is  highly  commended  by  Dr. 
Edwin  Payne,  of  London,  for  its  painlessness  and  for  its  power  in 
keeping  the  surface  in  a  more  healthy  condition  and  free  from  offensive 
odor.  The  strength  used  is  a  drachm  of  the  tincture  to  eight  ounces 
of  water, 

Vallet's  mass,  administered  in  doses  of  from  five  to  ten  grains  a 
day,  has  been  recommended  by  Prof  H,  H.  Smith,  One  case,  as 
an  example,  is  mentioned  by  this  surgeon,  where,  having  been 
consulted  with  a  view^  to  operating,  and  having  declined  on  account 
of  the  rapid  advance  of  the  disease,  he  suggested  the  use  of  this 
medicine,  conjoined  with  the  application  of  the  powdered  carbonate 
to  the  sore,  and  the  patient  lived  eight  years  without  the  di.sease 
having  made  any  very  great  progress. 

Justamond,  of  London,  also  favored  the  internal  use  of  iron,  and 
was  in  the  habit  of  giving  from  sixty  to  one  hundred  and  twenty 
grains  of  the  ammouio-chloride  a  day.  Dr.  Carmichael,  of  Dublin, 
expressed  himself  as  having  derived  much  benefit  from  washing  the 
ulcerations  with  a  solution  of  sulphate  of  iron. 

Chloride  of  zinc  and  solutions  of  the  salt  are,  in  this  direction, 
favorite  preparations  :  its  power  to  arrest  phagedenic  action  is 
remarkable:  the  medicine  has  more  than  a  cauterant  property;  it  is 


EPITHELIOMA.  929 

peculiarly  alterative.  Judiciously  applied  to  any  indolent,  irritable, 
or  bad  ulcer,  it  will  be  found  to  influence  markedly  to  a  change  for 
the  better. 

Concerning  the  use  of  this  agent  in  cancer,  we  have  many  com- 
mendations, particularly  from  European  surgeons;  but,  as  can  be 
very  readily  apprehended,  nowhere  in  the  range  of  its  application 
is  more  judgment  required  for  a  judicious  employment  than  here,  for 
it  is  a  cauterant,  a  stimulant,  an  antiseptic,  and  an  alterative.  Dr.. 
Zuerine,  of  Vienna,  relates  a  case  of  cancerous  ulceration  of  the 
septum  nasi  which  threatened  to  destroy  the  whole  nose;  one  grain 
and  a  half  of  the  chloride  of  zinc,  he  says,  were  dissolved  in  one 
ounce  of  distilled  water,  and,  the  scabs  being  removed,  the  sore  was 
penciled  over  several  times  a  day  with  the  solution  ;  at  the  end  of  a 
fortnight  a  healthy  granulating  surface  was  found  underneath  the 
thick  crust  which  covered  the  sore,  and  this  being  occasionally  re- 
moved, and  the  solution  reapplied,  it  cicatrized  in  five  weeks. 

Mr.  Tuson  has  published  some  cases  to  show  the  value  of  cer- 
tain preparations  of  chlorine  in  cancerous  affections.  In  one  which 
he  refers  to  there  was  an  extensive  cancerous  affection  of  the  right 
breast  and  neck,  which  was  treated  unsuccessfully  for  a  long  time, 
till  a  paste  was  applied,  made  of  one  part  of  chloride  of  zinc  to  three 
of  flour;  this  was  well  mixed,  and  moistened  with  water,  and  then 
applied  over  the  ulcerated  parts.  The  zinc  was  also  given  internally ; 
half  a  grain  was  ordered  in  a  wineglassful  of  caraway-water  every 
morning.  The  chloride  of  zinc  paste  was  applied  again,  and  when 
the  slough  separated,  the  ulcerated  surface  healed  kindly.  The  can- 
cerous deposition  continued  for  some  time,  and  the  dose  of  the  metal 
was  increased  to  three-quarters  of  a  grain  and  continued  for  three 
months.  The  improvement,  although  very  striking,  was  not  per- 
manent, as  the  patient  sufl'ered  a  relapse  which  ended  fatally.  The 
case,  however,  was  suflBcient  to  show  that  the  treatment  had  made 
considerable  impression  on  the  disease,  and  especially  in  healing 
the  open  cancer,  which  Mr.  Tuson  had  found  to  be  the  result  in 
several  other  cases. 

The  great  suffering  associated  with  carcinoma  makes  necessary  the 
free  use  of  opiates,  both  locally  and  internally.  Stramonium,  bella- 
donna, aconite,  opium  and  its  preparations,  hamamelis,  are  highly 
recommended.  As  much  as  twenty  grains  of  sulphate  of  morphia  have 
been  administered  during  the  course  of  a  single  twenty-four  hours  in 
certain  rare  cases.  Injections  by  the  subcutaneous  method,  where 
morphia  is  to  be  long  continued,  are  now  generally  resorted  to. 

58 


930  OBAL  DISEASES  AND  SURGERY. 

Batley's  solution  answers  best  for  this  manner  of  use.  For  con- 
tinuous stomachic  administration  of  the  opiate  preparations,  prefer- 
ence is  to  be  given  to  the  bi-raeconate  of  morphia;  the  ofiBcinal 
strength  of  this  medicine  is  tljat  of  hiudanum,  twenty-five  drops 
representing  one  grain  of  opium. 

A  complication  sometimes  occurring  with  epithelioma  about  the 
mouth  is  the  supervention  of  erysipelas.  A  jjcculiarity  of  these 
.  cases  is  that  the  erysipelas  does  not  exhibit  its  specific  complexion, 
but  a  patient  is  found  to  look  as  if  in  a  few  hours  his  disease  had 
made  more  progress  than  before  in  months,  or  perhaps  in  years. 
The  best  treatment  the  author  has  found  for  such  a  complication 
consists  in  the  use  of  what  on  a  previous  page  has  been  alluded  to 
as  almost  a  specific, — the  proportions  being  varied  to  suit  cases  : 

R. — Tinctura3  ferri  chloridi,  5'j  ; 
Quiniae  sulphatis,  gr.  xv; 
Tincturse  cinchonas,  5ij  to  §ss.     M. 
S.   To  be  brushed  over  the  parts. 

Another  complication  occasionally  met  with  is  the  existence  of 
salivation.  The  author  once  had  as  a  patient  a  lady  who  was  com- 
pelled to  keep  a  wash-bowl  constantly  upou  her  lap ;  the  water 
literally  flowed  from  her  mouth. 

Of  cases  of  epithelioma,  cancerous  and  otherwise,  met  with  from 
time  to  time  by  the  author,  the  most  interesting  variety  might  be 
illustrated.  Unable,  however,  to  allow  more  space  to  the  subject, 
the  condition  must  be  dismissed,  with  a  suggestion  to  the  inexperi- 
enced to  inform  themselves  of  its  many  and  peculiar  phases  by  an 
examination  of  clinical  records ;  every  service  being  rich  in  such 
experience. 


PLATE    VIII. 

APPEARANCE   AND    POSITION   OF    SOME    OP    THE    TUMORS    SEEN    ABOUT 

THE    NECK. 

Fig.  1. — A  large  Cystoma  of  the  right  parotid  region,  caused  by  the  devel- 
opmect  of  a  sebaceous  follicle  in  consequence  of  a  blow  upon  the 
part.  Commencing  as  a  lump  the  size  of  a  nut,  this  tumor  gradu- 
ally increased  to  nearly  the  size  of  the  head ;  gave  exit  at  one 
time  to  sebaceous  matter ;  had  a  broad  base  ;  was  nearly  immov- 
able ;  had  the  veins  enlarged  upon  its  surface,  and  showed  a  small 
ulceration  in  front  from  which  fetid,  acrid,  and  bloody  sanies  had 
escaped.  As  the  tumor  enlarged,  the  jaw  became  closed,  sensation 
of  the  face  diminished,  and  there  were  all  the  other  symptoms  due 
to  pressure  on  the  vessels  and  nerves  of  the  part.  The  tumor  dif- 
fers in  appearance  from  scirrhus  of  the  parotid  gland  in  its  size 
and  period  of  development.  It  was  readily  removed,  and  is  rep- 
resented as  an  example  of  one  of  the  class  of  tumors  of  the  parotid 
region  not  involving  the  parotid  gland. — After  Auvert. 

Fig.  2. — Large  Adenoid  Tumor  of  the  Neck  dependent  on  degeneration  of 
the  lymphatic  glands  of  the  neck.  Arising  as  a  small  swelling 
caused  by  an  enlarged  gland  below  the  angle  of  the  jaw,  it  gradu- 
ally increased  until  it  occupied  the  entire  side  of  the  neck,  in- 
volving many  glands,  and  reaching  from  above  and  behind  the  ear 
to  below  the  clavicle,  so  as  to  turn  the  head  to  the  opposite  side. 
Its  appearance  was  that  of  an  irregularly  lobulated  mass:  it  was 
unaccompanied  by  pain,  was  perfectly  firm  and  hard,  and  gave  no 
sense  of  fluctuation  at  any  point.  Under  the  use  of  chloroform 
it  was  successfully  removed  by  Mott. — After  Mott. 

Fig.  3. — Appearance  of  an  immense  Adipose  or  Lipomatous  Tumor  of  the 
Neck.  This  tumor  was  not  painful ;  had  no  pulsation  ;  was  formed 
of  numerous  large  lobes,  with  the  superficial  veins  distended  over 
them,  and  was  attached  to  the  neck  by  a  large  pedicle  which  ex- 
tended from  the  angle  of  the  lower  jaw  on  the  right  side  down  to 
the  sterno-clavicular  articulation,  its  weight  being  so  great  that 
the  patient  could  hardly  retain  the  erect  position.  The  tumor  was 
found  to  be  covered  by  a  strong  capsule  formed  of  the  surround- 
ing cellular  tissue,  and  to  have  originated  in  a  hypertrophy  of  the 
surrounding  adipose  tissue. — After  Auvert. 

Fig.  4. — A  large  Cystoma  of  the  left  Parotid  and  Submaxillary  Regions, 
which  was  to  the  touch  semi-elastic,  unequally  lobulated,  and  due 
to  a  chronic  irritation  of  one  of  the  sebaceous  follicles,  the  duct 
of  which  had  become  closed,  and  thus  caused  a  retention  and 
degeneration  of  its  secretion. — After  Auvert. 

(  931) 


CHAPTER    XLY. 

TUMORS   OF    PARTS    ASSOCIATED    WITH    THE  MOUTH. 

The  sebaceous,  the  cystic,  the  fatty,  and  the  glandular  tumors  are 
those  most  frequently  found  in  association  with  the  integuments. 

The  first,  the  sebaceous,  are  perhaps  the  most  common,  and  are 
as  simple  in  nature  as  they  are  easy  of  cure.  As  the  result  of  a 
blow  or  other  cause,  the  orifice  of  one  or  more  of  the  ducts  of  the 
sebaceous  glands  becomes  obstructed  ;  the  secretion  continuing  and 
having  no  outlet,  becomes  necessarily  accumulated  ;  hence  the  grad- 
ual expansion  of  the  duct  and  formation  of  a  tumor.  As  this  tumor 
continues  to  enlarge,  it  becomes  more  and  more  solid,  the  result  of 
the  absorption,  or,  if  not  this,  at  any  rate  the  disappearance,  of  its 
more  liquid  contents,  until  finally,  to  the  touch,  it  becomes  springy 
and  elastic.  A  section  of  such  a  tumor  exhibits  a  delicate  cyst  wall 
or  envelope,  and  cheesy  or  semi-cheesy  contents ;  it  is  seen  to  lie  in 
the  integument  as  distinctly  as  a  walnut  lies  within  its  hull. 

Sebaceous  tumors  are  found  of  every  size,  varying  from  that  of  a 
hazel-nut  to  that  of  a  foetal  head ;  they  are  generally  spheroidal  in 
shape,  but  frequently,  because  of  influences  exerted  by  neighboring 
parts,  become  changed,  even  to  a  lobulated  character. 

The  diagnosis  of  a  sebaceous  enlargement  is  generally  not  at  all 
difficult:  the  tumor  rolls  under  the  touch,  can  be  circumscribed  by 
the  gra.sp,  has  a  detached  feel,  as  if  confined  to  its  place  alone  by 
the  skin;  the  tissues  enveloping  it  are  perfectly  healthy,  while, 
however  large  it  may  be,  no  evidences  are  given  of  constitutional 
association.  Exceptions,  however,  exist  to  this  simplicity  in  some 
special  cases,  as,  for  example,  where  the  presence  of  the  tumor  has 
excited  inflammation  in  the  surrounding  parts,  thickening  the  cyst 
and  forming  attachments,  or  where  the  attenuated  skin  has  ulcer- 
ated, or  where  the  contents  of  the  cyst  have  degenerated. 

Sebaceous  growths  are  most  easily  got  clear  of  by  operation. 
In  many  cases  it  is  onl)^  necessary  to  make  a  sufficient  incision  in 
the  skin,  and  the  tumor  can  be  enucleated,  just  as  the  crystalline 
(  932  ) 


TDMOBS   OF  PARTS  ASSOCIATED    WITH  MOUTH..     933 

lens  is  removed  in  the  operation  for  hard  cataract.  In  other  cases 
it  is  necessary  to  incise  the  tumor  through  its  centre  down  to  the 
base  ;  this  exposes  the  cyst  or  sac,  which  is  to  be  dissected  away. 
In  instances  of  moderate  or  large  growths  it  is  the  practice  to  com- 
mence with  an  elliptical  incision,  making  the  skin  removed  correspond 
with  the  requirements  of  the  parts  after  the 
tumor  shall  have  been  taken  away.  In  doing 
this  it  will  be  found  much  better  to  have  too 
much  than  too  little  integument :  even  very 
large  flaps  will  be  found  soon  to  accommodate 
themselves  to  the  parts  beneath. 

The  contents  of  sebaceous  tumors,  while 
really  uniform  in  character,  var^^  greatly  not 
only  in  consistence  but  in  appearance.  Yet, 
whatever  the  expression,  the  springy,  elastic 
character,  as  the  touch  is  concerned,  is  pre- 
served. These  tumors,  while  very  frequently 
multiform  when  appearing  upon  the  scalp,  s„,aii  sebaceous  Tumor, 
where  they  are  known  as  the  common  wen,  showing  its  sacculated  cou- 
seldom  appear  but  as  single  upon  the  face. 

Sebaceous  tumors  have  little  vascularity,  the  supply  of  vessels 
being  confined  to  the  sac,  which,  as  will  be  inferred,  is  the  attenu- 
ated duct  and  glandular  substance  :  hence  the  growth  is  of  very 
slow  character.  Little  or  no  pain  attends  the  development,  and 
the  enlargement  is  entirely  devoid  of  danger,  as  any  tendency  to 
malignant  degeneration  is  concerned.  The  sac,  because  of  attach- 
ments which  it  has  formed  outside,  is  generally  on  such  aspect  rough 
and  cellular-looking;  on  the  inner  face,  on  the  contrary,  it  is  smooth 
tand  glistening. 

Cystic  Tumors. — Cystic  tumors,  or,  more  correctly  speaking, 
cellulose  tumors,  are  of  occasional  appearance  in  the  cheeks.  They 
might  be  described  as  a  puffiness  of  the  subcutaneous  cellular  tissue, 
and  would  be  very  well  represented  by  considering  them  as  made 
up  of  a  number  of  air-  or  serum-injected  cells,  grouped  together, 
and  limited  by  the  adjacent  fasciae.  The  skin  above  such  tumors  is 
always  attenuated  and  generally  discolored,  even,  at  times,  to  an  ap- 
proach to  purple,  looking,  indeed,  as  if  just  ready  to  slough  away,  and 
yet  being  tenacious  of  vitality  to  an  extent  quite  wonderful.  Similar 
tumors  are  occasionally  found  in  the  substance  of  the  lips,  but  are 
much  more  apt,  in  this  situation,  to  be  made  up  of  a  single  cell  rather 
than  of  many.     In  origin  these  cysts  may  be  said  to  be  idiopathic, 


934  ORAL  DISEASES   AND   SURGERY. 

coming,  as  it  were,  of  themselves,  and  occasionally  disappearing  as 
spontaneously,  having,  in  the  interim,  failed  to  respond  in  the 
slightest  degree  to  treatment. 

These  tumors,  unless  in  situations  which  permit  of  the  use  of  the 
knife,  which  is  their  effectual  cure,  are  found  very  difficult  to  manage  : 
the  only  thing  that  ever  seemed  to  me  of  the  slightest  service  was 
the  daily  smearing  of  the  surface  with  creasote  ointment,  and  this 
practice  will  be  found  unsatisfactory  enough.  In  their  treatment  I 
have  broken  up  the  cells,  have  laid  the  tumor  open  in  bulk,  and 
stuffed  the  cavitv,  have  used  every  conceivable  kind  of  injection, 
and  then,  completely  discouraged  and  baffled,  have  left  the  case  to 
nature,  which,  after  six  months,  or  it  nn'ght  be  a  year  or  more,  would 
finally  effect  a  cure. 

The  most  common  seat  of  such  tumors  is  over  the  line  of  the 
Stenonian  duct;  and,  if  I  had  not  succeeded  in  satisfying  myself 
thoroughly  to  the  contrary,  I  would  have  to  believe  that  some  con- 
nection existed.  Whether  cured  by  nature,  with  or  without  assist- 
ance, they  are  peculiarly  liable  to  recur.  I  have  known  them  appear 
and  disappear  as  many  as  half  a  dozen  times.  They  seldom  rise 
much  above  the  level  of  the  cheek,  are  oblong  in  shape,  and,  indeed, 
look,  at  times,  more  like  a  varicose  vein  with  hypertrophied  valves 
than  anything  else  to  which  one  might  compare  them. 

Another  kind  of  cystic  tumor,  appearing  in  the  integuments  of 
the  face,  occasionally  met  with,  may  be  compared  to  a  cyst  of  car- 
tilage. Such  cysts  seem  to  prefer  as  a  locality  the  side  of  the  nose, 
and  when  in  thi.s  situation  are  connected  with  the  lateral  cartilages. 
If  opened  from  beneath,  they  will  discharge,  on  compression,  a  pus- 
like fluid,  but,  in  a  very  few  minutes  after  such  pressure  is  removed, 
will  refill,  or  will  at  least  reassume  their  original  form,  recovering, 
perhaps,  by  the  elasticity  which  resides  in  them. 

Another,  and  the  only  other,  situation  in  which  I  have  met  with 
such  tumors,  is  in  the  substance  of  the  lip;  but  here  they  more 
resemble  fibro-cartilage  than  when  upon  the  side  of  the  nose.  Ex- 
tirpation by  the  knife  is  the  proper  treatment,  although  it  not  uufre- 
quently  happens  that  a  cure  may  be  effected  by  cutting  into  the  cyst, 
scarifying  its  walls,  and  stuffing  with  medicated  lint;  the  tincture  of 
iodine  being  used  first,  and  alum-water  and  capsicum  after.  The 
illustration.  Fig.  290,  although  not  made  to  sho;v  such  tumors,  is 
almost  a  photograph  of  them  as  occasionally  met  with. 

Fatty  Tumors. — The  fatty  tumors  are  much  more  common  to 
the  posterior  and  lateral  aspect  of  the  neck  than  to  the  face.    Wher- 


TUMORS   OF  PARTS  ASSOCIATED    WITH  MOUTH.     935 

ever  they  may  appear,  however,  they  are  recognized  by  their  extreme 
slowness  of  growth,  by  the  tissues  overlying  them  being  unaffected, 
and  by  the  absence  of  pain  and  of  constitutional  association.  To  the 
touch  they  are  not  so  expressive,  beiug  at  one  time  springy  and 
elastic,  at  another  dull  and  doughv.     Being  a  hypertrophy  of  the 

Fig.  290. — Cartilaginous  Cyst. 


common  fatty  tissue,  these  growths  are  not  so  distinct  and  circum- 
scribed as  are  the  sebaceous,  consequently  are  of  broader  and  more 
diffused  base ;  such  tumors  may  or  may  not  be  sacculated,  such  sac- 
culation, however,  referring  to  a  very  imperfect  cyst  even  when  any 
signs  of  one  may  be  present.  Fatty  tumors  seldom  manifest  any 
tendency  to  degeneration,  troubling  more  from  a  constantly  increas- 
ing bulk,  and  the  annoyance  of  their  presence,  than  from  any  real 
harm  inflicted.  Fig.  3,  in  Plate  VIII.,  represents  a  most  unusual 
form  of  the  lipomatous  tumor.  In  this  instance  the  growth,  from  its 
very  weight,  has  become  pedunculated,  the  vascular  enlargement 


936 


ORAL  DISEASES  AND  SURGERY. 


Fig.  291. 


being  a  natural  and  simple  result  of  mechanical  interference  with  the 
circulation.  Fatty  tumors  are  only  to  be  treated  by  the  knife  ;  it  is 
simply  a  waste  of  time  to  try  other  means. 

Glandular  or  Adenoid  Tu.mors. — Glandular  tumors,  repre- 
sented in  Plate  YIII.,  Fig.  2,  belong 
markedl}',  although  not  exclusively,  to 
the  scrofulous  condition,  being  found 
most  generally  upon  persons  so  affected. 
These  tumors  are  commonly  situated 
upon  the  side  of  the  neck,  involving  one 
or  more  of  the  superficial  ganglionic 
chain.  In  undecided  cases  I  have 
known  them  of  such  torpidity  that  two 
or  three  years  would  scarcely  s\iffice  to 
develop  them  to  the  size  of  a  walnut, 
while  in  other  cases  the  enlargement 
will  be  so  rapid  that  a  few  months  may 
be  sufficient  to  obtain  the  prominence 
marked  in  the  plate.  Unlike  the  pre- 
vious classes  of  growth,  the  adenoid 
tumors  are  very  susceptible  to  constitutional  and  local  treatment, 
being  in  such  manner  quite  as  frequently  caused  to  disappear  as  by 
the  use  of  the  knife. 

Where  they  appear  upon  the  face,  such  tumors  imply  the  enlarge- 
ment of  the  buccal  glands;  in  these  instances  they  are  not  so  apt  to 


Lobulated  Liponmfoiis  Tumor- 
after  Miller. 


Fig.  2;i2. 


Fig.  293. 


Microscopic  Structure  of  an  Adipose 
Tumor  (Bennet). 


View  of  Fatty  Tiinior  removed  from 
under  the  Tongue  (Liston). 


have  the  scrofulous  association  as  when  found  upon  the  neck.     In 
considering  such  growths,  we  are  primarily  to  investigate  the  cause 


TUMORS  OF  PABTS  ASSOCIATED    WITH  MOUTH.     937 

or  causes  exciting  to  their  development.  Scrofula,  the  coramoa 
cause,  has  been  to  some  extent  considered  in  another  part  of  this 
work ;  its  general  recognition  as  a  dyscrasic  disease  suggests  the 
necessity  of  such  a  course  of  medication  as  shall  tend  to  restore  the 
lost  tone  and  build  up  the  system  at  large  ;  hence  the  use  of  tonics 
so  freely  prescribed  in  such  connection.  Regarding  the  local  reme- 
dies to  be  employed,  a  common  preference  seems  to  be  given  to  the 
iodine  in  tincture.  Overstimulation,  however,  it  is  not  to  be  forgotten, 
is  quite  as  bad  as  no  stimulation  at  all, — perhaps  even  worse;  and 
by  a  too  free  use  of  this  agent  even  more  harm  than  good  may  be 
done.  Harmony  in  the  system  at  large  being  secured,  it* will  be 
found  to  need  very  little  local  stimulation  to  provoke  absorption  in 
the  tumor;  hence  a  philosophical  treatment  of  such  cases  considers 
not  only  medicaments  proper,  but  the  bath,  dress,  food,  exercise,  etc. 

A  local  treatment  to  be  used  in  very  indolent  growths  consists  of 
equal  parts  of  the  belladonna  and  mercurial  ointments.  Such  an 
ointment,  in  my  experience,  causes  these  tumors  to  be  absorbed  very 
rapidly,  or  else  to  degenerate  into  pus.  I  have  used  this  combination 
in  many  cases  with  the  most  satisfactory  results. 

Another  mode  of  treatment  is  by  the  blister.  For  this  purpose 
the  cantharidal  collodion  will  be  found  admirably  adapted.  Blisters 
should  be  in  proportion  to  the  size  of  the  tumor,  never  covering 
more  than  an  eighth  or  a  quarter  of  its  free  surface. 

In  cases  where  it  may  be  thought  preferable  to  use  the  knife, 
should  the  tumor  be  upon  the  face,  the  incisions  are  to  be  made  in 
the  line  of  the  underlying  muscles,  thus  insuring  the  slightest 
possible  amount  of  deformity  from  the  scar. 

Adenitis  from  a  syphilitic  association   may  yield  tumors  of  the 

cervical  and  buccal  glands.      A   diagnosis  in   these  cases  is   had 

from  the   history  of  the  case,  or,  if  this  is  not  to  be  procured,  an 

enlargement  will  always  i)e  found  to  be  associated  in  the  posterior 

cervical  chain.     This  is  a  most  diagnostic  sign,  and  will   seldom 

mislead. 

ACCIDENTAL  TUMOES. 

Tumors  of  the  parts  we  are  considering,  which  might  be  termed 
accidental,  are  the  erectile,  the  lepidoid,  the  verrucous,  the  keloid, 
and  the  horny. 

AngionOxMA,  Vascular,  or  Erectile  Tumors. — Under  this  desig- 
nation are  included  naevi  materni,  or  mother-marks,  and  the  venous, 
arterial,  and  capillary  growths. 

Naevi,   as  suggested  by  Professor   Smith,  cannot  always  come 


988  OBAL  DISEASES  AND  SURGERY. 

justly  under  the  designation  of  tumors,  from  the  fact  that  they 
frequently  exist  without  apparent  elevation;  situated  in  the  skin, 
yet  producing  no  visible  thickening  of  it.  These  marks  are  of  very 
various  size,  form,  and  color,  being  sometimes  found  several  inches 
in  length,  and  again  as  mere  spots.  In  form  they  may  represent 
certain  familiar  objects,  as  fruits,  animals,  etc.  The  color  of  them, 
generally  some  shade  of  red,  varies  from  the  arterial  scarlet  to 
the  dull  purple  of  a  venous  congestion.  Naevi,  even  although  to 
the  eye  they  may  not  in  many  instances  appear  vascular,  certainly 
differ  only  in  degree  from  the  telangiectasis,  being  commonly  capil- 
lary hypertrophies,  as  is  sufficiently  witnessed  when  wounds  occur 
in  them.  That  such  vascularity  does  not,  however,  shade  off  into 
the  adjoining  tissue  is  sufficiently  well  recognized;  on  the  contrary, 
the  connection  is  very  limited.  Such  tumors  are  supplied  by  two 
or  three  large  vessels,  the  hypertrophy  of  whose  radicles  may,  for 
practical  purposes,  be  viewed  as  constituting  the  tumor  or  disease: 
hence,  in  operating  on  such  growths,  if  the  incisions  are  made  wide 
of  the  growth,  there  is  perhaps  no  more  than  ordinary  hemorrhage, 
— only  one  or  two  vessels  requiring  the  ligature. 

Arterial  Tumor. — This  is  a  form  of  the  erectile  growths  which 
has  an  individuality,  inasmuch  as  it  consists  of  a  congeries  of  vas- 
cular twigs,  held  together  by  the  more  or  less  imperfect  remains 
of  the  associated  skin  and  cellular  tissue.  That  it  is  not,  as  has  been 
suggested,  an  aneurism,  but  rather  a  simple  enlargement  of  ter- 
minal vessels,  is  proven  b\'  the  fact  that  such  enlargement  accom- 
panies the  vessels  of  supply  for  a  greater  or  less  distance ;  that  it 
differs,  however,  from  the  nasvi,  just  described,  few  are  prepared  to 
admit.  It  is,  perhaps,  a  formidal)le  nievus,  but  it  is  nothing  more, 
both  being,  in  varying  degrees,  erectile  tumors. 

These  growths,  while  in  many  instances  referable  to  local  injuries, 
are  in  most  cases  fairly  to  be  presumed  of  congenital  character.  It 
is  quite  true  that  they  may  appear  even  later  in  life,  yet  the  impress 
existed,  although  it  may  have  been  but  a  little  red  spot  not  larger 
than  the  head  of  a  pin,  and  may  have  entirely  escaped  attention. 

The  growth  of  such  tumors  is  markedly  variable.  I  have  met 
with  them  where  twenty  years  seemed  scarcely  to  have  changed 
their  character,  while  in  other  instances  a  single  week  has  exhibited 
alarming  progress.  In  some  cases  the  attenuation  of  the  coats  of 
the  vessels  is  so  great  that  one  might  well  imagine  he  can  see  the 
flow  of  the  blood,  while  in  other  instances  a  hypertrophy  of  the 
associate  tissues  is  so  marked  as  comparatively  to  solidify  the  part. 


TUMORS   OF  PABTS  ASSOCIATED    WITH  MOUTH.     939 


In  color  the  arterial  tumor  will  also  be  found  to  vary,  the  shading 
being  influenced  by  the  conducting  facility  of  the  veins  which  are 
to  pass  off  the  circulation.  Pulsation  exists  in  many  of  the  eases, 
and  is  synchronous  with  the  ventricular  S3-stole.  To  tlie  touch  the 
tumors  are  soft  and  doughy,  almost  disappearing  under  pressure, 
yet  filling  up  the  moment  such  pressure  is  removed  ;  they  have  no 
definite  form,  the  outline  being  modified  by  circumstances  of  which 
we  know  nothing.  One.  marked  diagnostic  sign  of  such  tumors 
is  the  effect  produced  on  the  size  by  the  condition  of  the  circula- 
tion;  veratrum  viride,  or  digitalis,  by  lowering  the  action  of  the 
heart,  will  almost  cause  those  of  moderate  size  to  disappear.  Even 
the  quietude  of  sleep  and  recumbencj^  markedly  affect  them.  Passion, 
on  the  other  hand,  excitement,  or  any  mental  emotion  disturbing  the 
pulse,  will  cause  them  to  enlarge,  even  in  some  instances  to  burst- 
ing, such  enlargement  being  most  pronounced  in  cases  where  a  state 
of  atrophy  ciiaracterizes  the  connective  tissue.  The  common  danger 
from  these  tumors  is  ulceration,  which,  in  many  instances,  resulting 
in  severe  hemorrhage,  has  gradually,  and  sometimes  suddenly, 
exhausted  the  patient. 

The  Yenous  Tumor.  —  This  is  another  form  of  the  erectile 
growths,  differing,  however,  from  the  one  just  described,  in  the  fact 
that  the  venous  rather  than  the  arte- 
rial twigs  are  in  a  state  of  enlarge- 
ment. A  description  of  the  one  is  a 
description  of  the  other,  save  in  the 
matters  of  color  and  pulsation,  the 
latter  being  generally  dark,  almost  to 
a  dull  purple  or  grayish-black,  and  of 
course  deficient  in  pulsation.  Like  the 
arterial,  the  venous  tumors  are  some- 
times slow  of  growth,  at  other  times 
rapid  ;  they  appear  without  assign- 
able cause  other  than  the  congenital 
impress. 

Treatment. — Na^vi  are  treated  on 
a  common  principle:  by  amputation  with  the  knife,  by  strangulation, 
by  starvation,  by  compression,  by  injection,  and  by  the  application 
of  caustic  remedies. 

Excision  is  chiefly  confined  to  small  tumors.  In  these  cases  ex- 
cision is  the  easiest  and  most  rapid  way  of  getting  clear  of  them. 
The  general  experience  to  cut  as  wide  of  the  growth  as  convenient 


Fig.  294. — Venous  Tumor. 


940 


ORAL  DISEASES  AND  SURGERY. 


is  the  principal  rule  ;  as  the  vessels  of  supply  are  cut,  an  assistant 
compresses  them  with  thumb  or  finger;  and  while  such  vessels  are 
frequently  very  formidable-looking,  yet  it  may  happen  that  when 
the  tumor  is  entirel}^  away  not  a  single  ligature  shall  be  required. 
Should  the  hemorrhage  not  cease,  it  will  be  found  the  easiest  matter 
to  catch  them  with  the  forceps  or  tenaculum  and  throw  a  ligature 
around  them. 

A  removal  effected,  and  the  bleeding  controlled,  nothing  remains 
but  to  close  the  wound  with  a  few  stitches  of  the  interrupted  suture, 
and  to  support  it  with  adhesive  strips. 

Strangulation,  the  most  common  mode  of  operation,  is  effected  by 
transfixing  the  tumor  with  one  or  more  ligatures,*  and  thus  sloughing 
it  away.     As  a  general  rule,  it  will  be  found  necessary  to  transfix 

Fig.  295. 


skin  as  well  as  tumor ;  but  should  cases  present  where  the  overlying 
parts  are  healthy,  a  crucial  incision  may  be  made,  and  the  flaps  laid 
off  before  such  transfixion ;  the  tumor  having  been  removed,  the 
flaps  are  laid  back  in  place,  and  dressed  secundum  artem. 


*  See  Operations  o?i  the  Tongue. 


TUMORS   OF  PARTS  ASSOCIATED    WITH  MOUTH.     941 


Fig.  295,  being  a  case  treated  by  Prof.  Paneoast,  exhibits  a  large 
vascular  tumor  of  the  lip,  which  found  its  complete  cure  in  the 
operation  practiced  ;  this  consisting  simply,  as  shown  in  the  diagram, 
in  passing  a  pin  and  compressing  upon  it  the  vessels  of  supply. 

The  strangulation  of  the  nsevi  not  unfrequently  requires  the  exer- 
cise of  considerable  ingenuity  in  the  arranging  of  the  ligatures.  Figs. 
296  and  297  exhibit  complexities  in  transfixion,  and  will  serve  as  hints 
in  practice. 

Fig.  296.  Fig.  297. 


Diagram  of  tumor  with  its 
base  transfixed  by  a  number 
of  threads. 


Diagram  of  tumor  with  its 
base  transfixed  by  threads  at 
right  angles  to  one  another. 


Compression  applies  to  pressure,  however  made.  Take  a  piece  of 
ivory,  metal,  or  other  convenient  material,  adapt  it  to  the  part,  and 
confine  by  means  of  bandage  or  adhesive  strips.  This  mode  of  cure 
is  rarely  applicable,  being  used  only  over  bony  surfaces  and  where 
the  tumor  is  quite  small.  A  practice  which  in  one  instance,  where 
the  tumor  was  situated  upon  the  finger,  answered  a  satisfactory  pur- 
pose, consisted  in  the  dail}^  application  of  tincture  of  iodine  four 
times. the  officinal  strength,  together  with  the  use  of  an  india-rubber 
ring.     Collodion,  daily  applied,  has  been  recommended. 

Injections  have  many  advocates:  of  agents  thus  used,  the  princi- 
pal are  iodine,  Monsel's  solutions  of  iron,  nitric  acid,  and  creasote. 
Such  mode  of  treatment  is  always,  however,  more  or  less  attended 
with  risk,  and  is  not  to  be  commended.  The  practitioner  disposed 
to  try  it  has  only  to  use  the  ordinary  subcutaneous  syringe,  break 
up,  with  its  point,  the  structure  of  the  tumor  or  some  portion  of  it, 
and  follow  with  the  injection.  Several  cases  of  death  are  on  record 
from  such  injections. 

Caustic  remedies,  used  to  destroy  such  tumors,  are  of  various 
kinds, — the  Vienna   paste   being  generally  preferred ;   this  is  the 


942  ORAL  DISEASES  AND   SUBGERY. 

potassa  cum  calce  of  the  Pharmacopoeia :  it  is  used  by  making  an 
application  of  from  ten  to  twenty  minutes,  following  it  with  an 
emollient  poultice. 

Another  method  is  to  paint  the  part  with  the  blistering  collodion, 
and,  after  the  cuticle  is  raised,  apply  crystals  of  the  chloride  of  zinc. 

In  the  application  of  any  caustic,  trouble,  more  or  less  severe, 
from  a  resulting  inflammation,  is  always  to  be  apprehended;  this 
every  patient,  or  the  friends,  should  be  made  to  understand,  as  it  is 
impossible  to  know  just  how  a  case  may  come  out.  After  the  use 
of  a  caustic  and  the  slough  of  a  part,  the  resulting  wound  is  to  be 
treated  as  a  simple  ulcer. 

Starvation  is  still  another  method  of  treating  the  erectile  growths. 
This  consists  simply  in  finding  the  vessel  or  vessels  of  supply,  and 
cutting  off  the  circulation  by  ligation  ;  this  mode  has  many  advo- 
cates, and  is  certainlv  a  good  one  where  the  vessels  are  in  a  position 
to  be  conveniently  operated  on. 

The  seton  is  still  another  mode.  This  is  introduced  by  threading 
the  needle  with  tape  or  other  niffterial,  and  passing  it  beneath  the 
growth.  The  seton,  whatever  the  material,  should  be  as  large  as 
the  needle  which  carries  it,  if  not  larger;  thus,  by  the  pressure 
secured,  guarding  against  hemorrhage. 

In  considering  the  treatment  of  iiaevi,  it  is  not  to  be  forgotten  that 
there  are  cases  which,  if  left  to  themselves  long  enough,  might 
effect  self-cure.  Young  children  afflicted  with  na^vus  are  hurried 
to  the  surgeon,  under  the  impression  that  it  must  necessarily  spread, 
and  that  therefore  the  sooner  the  disea.se  is  removed  the  better. 
Such  haste  will  not  always  be  found  necessary,  or  even  prudent. 
For  a  short  time  after  birth  a  nsevus  may  continue  to  grow, — for 
several  weeks,  perhaps  ;  then  it  may  cease  to  enlarge.  If  it  is  of  a 
simple  cutaneous  variety,  it-  may  become  the  seat  of  ulceration  ; 
this  may  spread,  but  it  will  destroy  the  nsevus.  In  other  instances, 
a  nievus,  after  growing  to  a  considerable  size,  will  become  the  seat 
of  atrophy, — will  dwindle,  slirink,  and  degenerate,  until  little  or 
nothing  of  it  is  left. 

Treatment  of  the  vascular  naevi  by  the  galvanic  cautery  is  at  pres- 
ent in  much  esteem.  Dr.  Maas,  of  Breslau,  has  collected  in  the  Archiv 
fiir  Klinische  Chirurgie  (vol.  xii.)  the  histories  of  one  hundred  and 
twelve  cases  of  naevus  treated  by  the  galvanic  cautery.  The  results 
were  as  follows:  Capillary  nsevus — cured,  32;  improved,  1  ;  result 
unknown,  1.  Cavernous  or  venous  naevus — cured,  72  ;  improved,  8 ; 
result  unknown,  1 ;  died,  3.     Arterial  or  racemose  naevus — cured, 


TUMORS   OF  PARTS  ASSOCIATED    WITH  MOUTH.     943 

2;  improved,  1.  Nsevus  combined  ivith  other  tumors — cured,  6; 
improved,  1  ;  result  unknown,  2.  He  deduces  from  the  examination 
of  the  cases  the  conclusion  that  the  galvanic  cautery  is  followed  by 
the  best  results  in  naevus,  and  is  much  safer  than  the  injection  of 
perchloride  of  iron  or  any  other  coagulating  fluid.  It  would,  how- 
ever, be  wrong  to  say  positively  that  the  remedy  is  indicated  in  all 
cases  of  naevus.  As  Virchow  has  well  remarked,  the  surgeon  must 
take  the  circumstances  of  each  case  into  consideration.  The  battery 
used  in  the  cases  referred  to  was  that  of  Middeldorpf. 

In  the  use  of  the  means  of  electrolysis,  the  difficulty  to  be  en- 
countered arises  from  the  fact  that  occlusion  of  a  venule  or  other 
radicle  seems  to  have  but  little  influence  upon  its  neighbors,  thus 
necessitating  repeated  operations  until  the  electrolytic  action  has 
directly  influenced  almost  each  individual  vessel.  Moreover,  since 
galvano-puncture  thus  cauterizes  the  tissues  as  well  as  coagulates 
the  blood,  it  is  evident  that  a  slough  must  ensue,  provided  the  super- 
ficial portion  be  much  affected ;  and  if  such  an  occurrence  must  take 
place,  with  its  consequent  cicatrix,  it  is  preferable  to  have  it  occa- 
sioned by  the  more  speedy  action  of  a  ligature.  The  slough  of 
galvano-puncture  is,  however,  perfectly  devoid  of  hemorrhage,  since 
it  is  tardy  in  its  separation  ;  and  it  is  remarkable  for  its  extreme 
dryness. 

These  objections  to  its  use  apply  only  to  naevi  which  are  super- 
ficial, or  where  the  skin  is  implicated.  In  subcutaneous  nsevi  the 
operation  possesses  the  advantage  of  being  safer  and  more  certain 
than  injection,  and  in  cases  where  no  slough  is  necessitateil  we  dis- 
pense with  the  scar  of  an  excision  or  ligation, — that  is,  provided 
insulated  needles  are  employed. 

A  Bunsen  or  other  battery  may.  be  used,  the  number  of  needles 
varying  with  the  size  of  the  tumor ;  but  in  all  cases  care  should  be 
taken  not  to  carry  the  action  beyond  the  whitish  hue  indicative  of 
cauterization.  In  regard  to  the  introduction  of  gas  into  the  circu- 
lation by  this  method,  I  do  not  think  there  is  the  slightest  danger 
in  cases  of  naevus,  notwithstanding  the  opinions  of  Rutherford  and 
other  able  writers  on  electro-therapeutics.  In  cases  of  huge  n^evi 
or  vascular  tumors,  this  course  might  be  pursued  with  advantage, 
especially  when  excision  is  hazardous.* 

*  "  Electrolysis. — Drs.  Beard  and  Kockwell,  in  the  Medical  Record 
for  July  15,  1872,  publish  some  of  their  results  in  the  use  of  electricity  in 
surgery : 


944  ORAL  DISEASES  AND   SURGERY. 

A  method  of  treating  naevi  practiced  and  highly  commended  by 
certain  English  surgeons  is  that  of  "piecemeal"  removal  ;  i.e.  tear- 
ing the  mass  away  fragment  by  fragment,  the  object  being  to  prevent 
hemorrhage,  on  the  same  principle  as  in  torsion  of  arteries. 

In  a  case  of  arterial  naevus  fully  the  size  of  a  walnut,  and  grow- 
ing very  rapidly,  situated  upon  the  cheek  of  a  young  babe,  a  very 
happy  cure  was  effected  by  strangulation.  Two  incisions,  two 
inches  long  and  crossing  each  other  at  right  angles,  were  made 
through  the  integuments,  and  the  four  flaps  dissected  from  off  the 
tumor.  The  knife  was  then  carried  through  healthy  tissue  com- 
pletely about  the  mass,  each  artery  being  compressed  or  picked  up 
as  it  was  divided,  so  that  comparatively  little  blood  was  lost.  As 
the  deep  portions  were  reached,  it  became  necessary  to  lay  aside 
the  knife,  by  reason  of  the  size  of  the  arteries,  and  a  strong  ligature 
was  then  thrown  around  the  base,  tightly  strangulating  the  remain- 
der and  cutting  off  all  nutrition.  The  wound  was  dressed  with  car- 
bolic acid  oil,  stimulants  and  anodynes  were  freely  given,  and  the 


"  In  the  treatment  of  erectile  or  vascular  tumors,  they  claim  for  electrolysis 
the  following  advantages  over  the  knife  or  other  methods:  there  is  no  hemor- 
rhage ;  there  is  no  scar ;  by  proper  management,  the  effect  produced  is  solely 
upon  the  blood  in  the  tumor ;  the  operation  is  easily  performed. 

"  In  proof  of  this,  they  adduce  cases. 

"  1.  A  child  aged  eight  months,  with  an  erectile  tumor  in  the  check.  Four 
needles  introduced  for  eight  minutes.  A  clot  was  produced,  which  was  wholly 
absorbed  in  four  months. 

"2.  A  large  tumor  in  the  back,  in  a  weakly  child  aged  one  year.  Same 
operutii'n.  liesult  unsatisfactory,  as  some  ulceration  followed,  and  the  tumor 
remained. 

"  3.  A  child  aged  fifteen  months,  with  a  tumor  near  the  angle  of  the  mouth. 
Four  needles  introduced  for  ten  minutes.  In  four  months  the  tumor  had 
disappeared,  and  no  scar  was  left. 

"  4.  A  subcutaneous  erectile  tumor  at  the  inner  angle  of  the  eye,  in  a  child 
aged  sixteen  months.  Three  needles  introduced  for  twenty  minutes.  Some 
sloughing  occurred  afterwards,  and  deformity  was  left.  The  authors  think 
too  strong  a  current  was  used,  and  for  too  long  a  time. 

"  5.  A  child  aged  eight  weeks,  with  a  na;vus  on  the  neck,  just  below  the 
chin.  One  needle  introdivced,  and  a  sponge  electrode  applied  externally,  for 
four  minutes.  Two  and  a  half  months  afterwards  there  were  signs  of  reap- 
pearance of  the  growth. 

"6.  Bronchocele  of  four  years' standing,  in  a  girl  aged  fourteen  years. 
External  galvanization  twice  a  week  for  two  months  failed.  Needles  intro- 
duced ;  in  four  months,  after  about  twenty  applications,  a  great  decrease  in 
size  in  the  tumor." 


TUMORS   OF  PARTS  ASSOCIATED    WITH  MOUTH.     945 

infant  soon  rallied.  On  the  fifth  day  the  slough  separnted,  and  the 
four  flaps,  which  had  before  been  left  loose,  were  then  laid  in  place 
and  secured  by  hare-lip  pins  and  interrupted  suture. 

A  case  of  cure  of  a  superficial  nsevus  involving  the  whole  of  the 
right  cheek  of  a  babe,  by  an  operation  performed  for  the  cure  of  a 
very  small  and  entirely  disconnected  one  situated  upon  the  lateral 
frontal  region,  occurred  only  a  short  time  ago  in  the  clinical  practice 
of  the  author. 

The  one  upon  the  cheek  was  formidable  in  appearance  and  size, 
and,  while  holding  its  method  of  cure  under  deliberation,  I  operated 
upon  the  smaller  one  by  strangulation  ;  this  soon  sloughed,  the  base 
rapidly  healing:  in  fact,  it  pursued  the  ordinary  simple  course. 
As  this  process  of  sloughing  went  on,  however,  a  singular  series  of 
phenomena  was  noticed  to  be  taking  place,  almost  pari  passu,  in 
this  naevus  upon  the  cheek  :  it  became  at  first  intensely  red,  theu 
purple,  advancing  to  livid,  until,  as  the  ligature  above  dropped  off, 
its  tegumentary  covering  also  ulcerated,  and  the  whole  nsevus  be- 
came a  sloughing  mass.  By  curing  the  little  one  above,  the  large 
one  below  was  cured. 

Melanoid  naevi  are  not  unfrequently  met  with.  For  an  illustrative 
example  and  consideration  of  these,  see  in  the  foot-note  the  clinical 
report  of  a  case  by  Dr.  De  Forrest  Willard.* 

*  "  M.  G.,  aged  forty-five  years.  Directly  in  the  centre  of  the  left  cheek 
of  the  woman*before  you,  will  be  noticed  this  blue-black  growth.  It  is,  as 
you  see,  oblong  in  shape,  shining  and  glistening  in  aspect,  and  isolated  by 
an  exact  line  of  demarkation  from  the  surrounding  parts.  In  length  it 
measures  just  one  and  a  half  inches;  in  prominence,  half  an  inch.  What 
is  it?  We  call  it  a  melanoid  nasvus  ;  that  is,  the  growth  is  an  ordinary 
najvus,  with  the  addition  of  a  great  excess  of  pigmentary  matter  ;  if  it  were 
not  black  it  would  show  itself  as  one  of  the  species  of  na3vi  we  have  so  fre- 
quently had  the  opportunity  of  examining  together,  and  every  one  of  you 
would  instantly  recognize  it.     It  is,  then,  only  the  red  face  painted  black. 

"What  is  pigment?  The  word  is  ivoxn  pingere,io  "paint;"  it  is  coloring- 
matter— paint — a  something  used  to  color,  and  is  found  in  varying  propor- 
tions throughout  the  different  races  of  man,  being  in  excess  in  the  African. 
The  white  race  has  least— the  Mongolian  and  Indian  stand  intermediate. 

"  The  nature  of  pigment  varies,  at  least  as  its  character  is  associated  with 
the  seat  of  deposit.  We  find  it  in  a  number  of  places  in  the  human  body  as 
a  normal  constituent  of  the  tissues  ;  in  the  internal  layer  of  the  choroid  coat 
of  the  eye,  for  instance,  there  is  a  dense  deposit  of  these  bhick  pigment-cells, 
forming  a  dark  background  to  the  sensitive  tetina. 

"This  membrana  pigmenti  is  composed  of  several  lamiinu  of  hexagonal 
cells,  which  appear  of  a  sooty-brown   color,  when  seen  singly  under  the 

69 


946  ORAL  DISEASES  AND  SURGERY. 

Moles. — MoU'=:  properly  belong  to  the  division  of  the  melanoid 
naevi,  consisting-  ;is  they  do  of  pigmented  hypertrophy  of  the  dermis 

microscope,  the  centre  being  pellucid,  and  the  pigment-granules  variously 
scattered  through  the  cell.  It  is  only  in  collected  numbers  that  they  show 
the  true  black  color.  This  layer  in  animals  is  of  considerable  depth,  and, 
being  of  metallic  brillianc}',  is  called  the  tapetum,  and  gives  that  well-known 
fiery  appearance  to  the  eyes  of  cats,  tigers,  etc.  in  the  night. 

'•  In  the  iris,  also,  we  find  pigment  of  various  colors,  while  again  in  its 
posterior  layer  are  found  those  purple  cells  which,  from  their  resemblance  in 
color  to  a  ripe  grape,  have  given  it  the  name  of  uvea. 

"  The  coloring-matter  of  the  hair  is  another  instance ;  but  enough  is  this 
mention  to  show  that  pigment  is  a  normal,  healthy  constituent  of  tissues,  and 
we  will  now  see  where  it  is  found  pathologically. 

"  Pigmental  degeneration  is  not  uncommon,  and  may  be  well  instanced  by 
the  graduallj'  accumulating  black  pigment  spotting  and  streaking  the  lungs  ; 
by  the  bronzing  of  the  skin  in  the  complaint  known  as  Addison's  disease,  and 
supposed  to  have  some  connection  with  the  supra-renal  capsules  (although  a 
case  is  reported  in  the  Medical  Press  and  Circular  for  March  8,  1871,  in  which 
no  lesion  was  found  in  these  bodies) ;  by  the  ash-colored  spots  sometimes  found 
in  the  mucous  membrane  of  the  stomach  or  intestines  of  old  people;  by  the 
black  spotting  or  deposition  of  these  granules  in  the  walls  of  the  arteries,  or 
even  in  the  tubes  themselves  of  some  animals,  which  seem  to  be  allied  to  fatty 
degeneration  in  our  own  arteries  ;  and,  finally,  even  by  the  frequent  granules 
deposited  in  the  arteries  of  our  brains  in  some  instances  of  disease  as  recorded 
/n  Virchow's  Archiv,  1859,  vol.  xvi.  p.  564. 

"  A  still  more  morbid  condition  is  seen  in  pigmental  degeneration  of  mu- 
cous corpuscles  in  the  gray,  smoke-colored  mucus  expectorated*at  the  close  of 
bronchitis ;  the  peculiar  color  which  has  usually  been  ascribed  to  carbon 
being  really  due  to  an  abundance  of  granules  in  the  cells,  which  closely 
resemble  those  already  spoken  of  as  giving  the  streaked  appearance  to  the 
lung.  Inhaled  carbon  may  be  present  in  such  mucus,  but  the  color  is  not 
cntirelj'  at  least  dependent  upon  it,  since  nitric  acid  or  chlorine  will  cause  it 
to  entirely  disappear.  In  fibrinous  lymph-corpuscles,  again,  we  have  another 
■evidence  of  this  same  degeneration  seen  in  the  various  shades  of  black  and 
gray  which  pervade  the  lymph  of  peritonitis,  which  shades  are  produced,  not, 
as  formerly'  supposed,  by  straining  from  intestinal  gases,  but  by  the  incorpo- 
ration of  free  pigment-granules.     [Rokitansky. — De  F.  W.] 

''Pigmental  adhesions  are  also  spoken  of  \>y  Paget,  in  which  black  spots 
appear  like  the  pigment-marks  of  the  lungs  and  bronchial  glands. 

"  Pigment-granules  of  all  kinds  greatly  resemble  each  other,  and  are  usually 
spherical  in  form.  They  are  sometimes  scattered  either  .spar.-ely  or  thickly 
throughout  the  cells,  being  also  often  found  in  free  liquid  ;  but  this  may  have 
been  from  an  overdistention  and  rupture  of  the  cells,  allowing  their  escape. 

"  Having  thus  seen  that  coloring-matter  is  found  both  normally  and  as  a 
product  of  degeneration,  let  us  see  if  it  progresses  still  further  to  give  rise  to 
what  we  call  melanosis. 


TUMORS   OF  PARTS  ASSOCIATED    WITH  MOUTH.     947 

and  epidermis.  These  growths  vary  greatly  in  size  and  general 
appearance,  but  are  too  familiar  to  every  one  to  need  special  descrip- 
tion. Usually  of  congenital  relation,  they  may  yet,  however,  have 
origin  in  a  long-continued  local  irritation.  If  situated  upon  the 
face — as  they  are  very  commonly — their  removal  becomes  a  desirable 
matter;  particularly  is  this  the  case  with  the  species  known  as  the 
hair-mole, — a  truly  repulsive  deformity. 


"  For  some  reason  not  clearly  understood,  an  excess  of  this  coloring-matter 
sometimes  pathologically  centralizes  itself,  as  in  the  instance  before  us,  and 
we  have  tumors  of  various  grades  of  colors,  according  to  the  proportion  of  tbe 
contained  pigmental  matter. 

"  Now,  melanosis  is  so  frequently  seen  in  association  with  m<  dullary  cancer 
that  we  have  come,  unduly  perhaps,  to  connect  it  with  this,  and  the  name  of 
'black  cancer'  has  been  given  it;  but  melanosis  is  not  cancer  ;  it  is  simply, 
as  we  understand  it,  an  anatomical  perversion, — an  expression.  The  tumor 
before  us  is  not  cancerous  ;  at  least  not  cancerous  because  it  is  black  instead 
of  red  ;  yet  it  has  an  unpleasant  look,  and,  as  usual,  causes  much  alarm  to  the 
patient  and  friends. 

"  That  moles  and  melanoid  njevi  do  tend  or  at  least  are  liable  to  degenerate 
is  undoubtedly  true ;  but  in  their  early  stages  their  structure  seems  simply 
that  of  natural  skin  and  epidermis  only  altered  by  the  deposition  of  a  little 
<?oloring-matter.  This  mole  upon  the  lady's  face  was  simply  a  disligurement 
until  recently,  when  it  commenced  to  grow ;  and  when  this  stage  of  activity 
is  reached  it  is  time  for  us  to  interpose  with  surgical  aid,  just  as  we  would 
when  a  wart  takes  on  epithelial  degeneration. 

"As  1  have  said,  the  cause  of  the  commencement  of  this  active  stage  is 
undetermined  ;  yet  when  a  constitutional  cancerous  element  is  co-allied,  then 
these  spots  seem  to  be  the  least  able  to  resist,  and  degeneration  begins, 
accompanied  soon  by  increase  in  size,  and  perhaps  by  twinges  of  pain.  Such 
a  stage  of  activity  may,  however,  never  occur,  and  many  such  naivi  or  moles 
are  carried  quietly  to  the  grave  of  persons  advanced  in  j^ears ;  and  yet  even 
at  a  late  day  rapid  development  of  the  disease  may,  and  has  occurred.  At 
first  such  commencing  cancer  can  but  be  seated  in  the  skin  and  subcutaneous 
connective  tissue,  differing  only  from  the  ordinary  expression  in  such  regions 
by  the  presence  of  a  little  pigment;  this  is  the  time  for  removal.  Their 
usual  primary  occurrence  near  the  seats  of  natural  pigments  shows  a  tendency 
to  conformity  with  the  character  of  the  adjacent  natural  tissues.  Tbe  melanosis 
of  the  books  cannot  be  regarded  otherwise  than  as  pigmental  degeneration  of 
cancer  expression,  the  granules  to  which  the  color  is  due  filling  the  cells  about 
the  nucleus,  and  finally,  perhaps,  changing  it  into  a  granule  mass,  thus  form- 
ing a  parallel  in  character  of  action  to  that  undergone  in  the  process  of  fatty 
degeneration.  "With  the  knowledge  now  that  these  dark  growths  arc  not 
without  danger  after  the  commencement  of  the  period  of  activity,  we  have 
no  hesitation  in  advising  this  woman  to  have  this  tumor  extirpated  at  once." 
— Author's  Clinic. 


948  ORAL  DISEASES  AND  SUBGERY. 

When  small,  no  better  plan  for  the  removal  of  these  growths  can 
be  adopted  than  to  circumscribe  the  tumor  by  an  incision  that  shall 
reach  to  the  underlying  fatty  tissue,  including  by  a  ligature,  which 
shall  occupy  the  line  of  this  incision,  the  growth,  and  thus  strangu- 
lating it.  When,  on  the  contrary,  the  mole  is  large,  it  is  best  treated 
by  being  included  in  an  ellipse,  which  shall  extend  to  such  depth  as 
to  afford  a  probability  of  immediate  and  permanent  union  of  the 
wound.  A  mole  removed  by  a  saucer-shaped  out-scooping,  leaves, 
in  the  healing,  a  cicatrix  almost  as  objectionable  as  the  deformity 
removed. 

Lepidoid  Growths. — The  lepidoid  growths  are  generally  mul- 
tiple, epidermic  in  character,  and  exhibit  themselves  as  elevated 
patches  of  varying  size,  scattered  irregularly  over  the  parts  affected, 
the  ordinary  localities  being  the  cheeks,  nose,  and  forehead. 

The  origin  of  the  term,  from  le-iq,  a  "  scale,"  and  dtviipov,  a  "tree," 
affords  the  idea  of  the  condition  the  part  presents,  simply  a  number 
of  scattered  bark-like  scales  separated  by  healthy  skin.  The  dis- 
ease, without  doubt,  is  most  common  to  persons  of  sandy  and  florid 
complexion,  having  light  or  reddish  hair,  with  marked  cutaneous 
circulation. 

Appearing  first  as  scales  not  larger  than  a  pin's  head,  the  disease 
may  year  by  year  progress,  until  finally  the  scales,  which,  like  all 
epithelial  tissues,  have  been  falling  off  and  renewing  themselves, 
cease  to  develop,  leaving  ulcers.  The  dermis  beneath  exhibits  a 
granular,  glossy  surface,  looking  like  limited  fungi  glazed  with 
lymph  ;  the  intermediate  skin  soon  becomes  dense  and  fibro-cartila- 
ginous,  and  if  the  disease  be  not  combated  a  cancerous  relation 
shows  itself. 

In  the  treatment  of  this  condition,  the  paint  composed  of  tincture 
of  iron  and  quinia  will  be  found  most  reliable.  If,  however,  it 
should  not  effect  an  immediate  good,  it  is  better  to  dispense  at  once 
with  its  use,  and  depend  strictly  upon  constitutional  influences,  the 
arsenicals  being  employed.  As  a  common  wash  or  simple  source  of 
protection,  bran-water  will  be  found  very  soothing.  A  local  appli- 
cation, as  follows,  has  also  been  highly  recommended: 

B. — Hydrargyri  bichloridi,  gr.  j ; 
Glycerinte, 
Aquae  Coloniae,  aa  ^ss.     M. 

Molluscous  Tumors. — This  form  of  growth,  not  unfrequently  to 
be  seen  upon  the  face,  derives  its  name  from  the  excrescences  met 


TUMORS   OF  PARTS  ASSOCIATED    WITH  MOUTH.     949 

with  on  maple-trees,  which  in  appearance  it  very  much  resembles. 
In  color  this  tumor  varies  from  a  brown  to  a  red,  being  most  com- 
monly, however,  of  a  dusky  yellow :  in  character  it  is  epithelioma- 
tous,  originating,  probably,  in  alterations  of  the  reflected  dermis  and 
epidermis  lining  the  hair-follicles. 

As  these  tumors  seldom  attain  a  size  greater  than  that  of  an  ordi- 
nary pea,  the  quickest  and  safest  cure  is  in  ablation,  either  by  knife 
or  ligature. 

YERRrcous  Growths — Warts. — Warts  upon  the  alee  of  the  nose 
are  familiar  objects  to  every  one.  They  consist  of  an  hypertrophy 
of  the  papillary  structure,  and  are  frequently  covered  with  a  sort  of 
secondary  growth,  as  in  what  are  known  as  the  seed-warts;  the 
structure  is  essentially  cellulo-6brous. 

Warts  are  not  only  objectionable  on  account  of  the  deformity  they 
produce,  but  when  situated  upon  the  face  they  seem  peculiarly 
inclined  to  degenerate,  assuming  a  vascularity  which  always  im- 
presses as  threatening.  In  treating  a  wart,  the  practitioner  may,  if 
he  choose,  first  apply  dilute  chromic  acid  ;  this,  in  many  instances, 
will  blacken  and  kill  the  growth,  the  tumor  sloughing  away  in  the 
course  of  five  or  six  days,  leaving  the  resulting  ulcer  a  perfectly 
simple  one.  But  chromic  acid  is  not  to  be  applied  to  the  vascular 
wart  ;  on  the  contrary,  if  irritable,  as  generally  first  seen  by  the 
practitioner,  it  is  to  be  soothed  by  the  gentlest  of  applications,  after 
which  it  is  to  be  thoroughly  removed  with  the  knife  or  ligature.  A 
good  rule  in  this  direction  is,  "  Do  not  irritate."  I  have  seen  many 
a  vascular  wart  provoked  into  the  most  alarming  aspect.  A  wart 
situated  upon  the  face,  unless  like  the  simple,  hard,  insensible  ex- 
crescence met  with  upon  the  hands,  cannot  be  too  carefully  or 
judiciously  treated. 

Keloid  Tumors. — Keloide,  the  French  term,  signifying  a  disease 
resembling  scirrhus,  is  the  name  given  to  one  of  the  most  peculiar 
and  inexplicable  of  the  skin  affections.  This  condition,  first  de- 
scribed by  Alibert,  is  characterized  by  nodules,  or  more  generally 
wheals,  scattered  irregularly  over  the  body, — usually,  however,  con- 
fined to  the  breast,  arms,  neck,  and  face.  It  occurs  in  both  sexes, 
may  appear  at  any  time  of  life,  and  is  thought  to  be  more  common 
to  the  black  than  to  the  white. 

Keloid  is  a  disease  of  the  skin  and  subcutaneous  cellular  tissue. 
That  it  is  an  atonic  condition  I  infer  from  the  fact  that  in  every 
individual  case  in  which  I  have  seen  it  there  seemed  to  be  a  scrofu- 


950 


ORAL  DISEASES  AND   SURG  ERF 


lous  association.  This,  however,  may  have  been  accidental,  as  I  do 
not  find  it  referred  to  by  others. 

As  to  the  exciting  causes  of  keloid,  dermatologists  express  no 
opinion:  it  is  traumatic,  and  it  is  idiopathic;  it  appears  upon  a  skin 
which  before  has  seemed  entirely  healthy,  and  it  springs  up  in  the 
cicatricial  tissue  of  a  wound.  The  cicatrices  of  bad  burns  from  dry 
heat  very  frequently  so  simulate  this  disease  that  one  might  be 
readily  mistaken  for  the  other.  Keloid  certainly  constitutes  a  dia- 
thesis :  I  have  seen  it  develop  after  a  simjjle  puncture  which  opened 
a  boil,  while  others  have  remarked  it  appearing  in  the  cicatrices  of 
smallpox,  after  scarification  in  cupping,  after  vaccination,  blistering, 
etc.  Processes  or  roots  pass  into  neighboring  parts,  thus  extending 
the  disease  ;  the  excrescences,  to  the  touch,  are  hard,  semi-elastic, 
and  rough  ;  the  color  differs  from  that  of  the  surrounding  parts — 
varying  as  do  the  cicatrices  of  burns.  According  to  some  observers,, 
the  parts  itch  and  are  more  or  less  uncomfortable.  I  have  myself, 
however,  never  heard  complaint  of  any  peculiar  sensation,  except, 
indeed,  as  the  location  of  some  wheal  would  interfere  by  its  stiffness 
with  free  motion  in  a  part. 

A  keloid  tumor  seems  to  be  an  imperfect  fibrous  development,  a 
species  of  fibroma. 

Treatment. — This  has,  in  e^-ery  instance,  proved  so  unsatisfac- 

P^iG.  298.— KKT.oiii   BfiA  OF  Nkck. 


tor}-,  that  surgeons  are  agreed  in  the  practice  of  letting  them  alone: 
even  the  knife  is  useless,  or  worse  than  useless  ;  if  a  nodule  or  wheal 


TUMORS   OF  PARTS  ASSOCIATED    WITH  MOUTH.     951 

be  removed,  one,  or  perhaps  half  a  dozen,  will  spring  up  in  its  place. 
Where  the  tumors  interfere  much  with  motion,  they  may  be  lubri- 
cated with  glycerin  or  oil,  but  otherwise  nothing  can  be  effected  by 
treatment:  the  only  comforting  reflection  for  the  patient  is  that 
keloid  seldom,  if  ever,  degenerates  into  cancer. 

Hornlike  Tumors. — These  tumors,  in  the  proportion  of  one-half 
the  cases,  appear  upon  the  face, — most  frequently  upon  the  forehead 
and  lips.  In  size,  as  well  as  in  general  appearance,  the  greatest 
variety  is  presented.  Allowed  to  grow,  they  have  been  met  with 
measuring  seventeen  inches  in  length.  In  the  British  Museum  is  a 
specimen  eleven  inches  in  length  by  two  and  a  half  inches  in  cir- 
cumference. A  casp  is  recorded  in  American  practice  where  such  a 
growth  measured  fourteen  inches  in  circumference  at  its  shaft,  and 
branched  into  three  divisions. 

A  horny  tumor  is  an  epithelioma,  and  finds  its  analogue  in  the 
human  nails.  Treatment  is  by  excision,  which,  if  thorough,  is  to  be 
depended  on  for  a  perfect  cure. 


CHAPTER  XLYI. 

OPERATIONS  UPON  THE  LIPS  AND  CHEEK. 

Hare-lip. — This  defect  consists  in  a  break,  single  or  double,  in 
the  continuity  of  the  lip.  The  deficiency  in  its  typal  form  is  almost 
precisely  similar  to  that  which  exists  naturally  in  the  hare  and 
rabbit,  having  from  this  resemblance  taken  its  name.  When  con- 
genital, it  is  always  found  associated  with  the  superior  lip. 

A  general  view  of  the  operation  for  the  relief  of  hare-lip,  and 
indeed  the  view  which  comprises  the  principles  of  the  cure,  is,  that 
the  margins  of  the  cleft  or  break  are  to  be  pared,  brought  together, 
and  held  in  apposition  until  nature  shall  secure  a  union.  There  are, 
however,  nice  surgico-artistic  associations  Avhich  are  to  be  studied  in 
connection  with  such  principles  of  operation.  Cutting  manipulations 
upon  the  face,  and  especially  about  the  lips,  claim  more  than  ordi- 
nary skill  and  judgment.  Such  skill  and  judgment  the  practitioner 
should  be  prepared  to  exercise,  if  not  for  humanity's  sake,  at  least 
for  his  own  credit  and  reputation  ;  for,  as  is  truly  remarked  by  the 
skillful  surgeon,  Mr.  Skey,  "  on  the  more  or  less  perfect  result  of 
such  operations  depend  the  appearance  and  expression  of  the  patient 
for  life."  And  surely,  just  so  far  as  an  operator  shall  beautify  or 
mar,  is  the  comfort  of  the  patient,  as  well  as  his  own  reputation, 
in'fluenced. 

A  proper  and  comprehensive  study  of  hare-lip  divides  itself 
naturally  into  three  subjects  of  special  signification: 

1st.  The  time  of  life  best  suited  to  the  operation.  (Considered  in 
foot-note.*) 

2d.  The  condition  of  the  patient, 

3d.  The  mode  of  operating. 

*  "  I  advise  you,"  says  Mr,  Listen,  "  to  defer  the  operation  till  the  first  set 
of  teeth  come  in,  and  I  have  seen  good  reasons  for  adhering  to  such  rule. 
"When  the  operation  is  undertaken  at  an  early  period,  there  is  often  great 
difficulty  ;  sometimes  union  does  not  take  place,  the  parts  turn  out  again,  and 
the  patient  is  rendered  more  deformed  than  in  the  first  instance.  When  the 
features  are  enlarged  somewhat,  you  have  more  ground  to  work  upon  :  you 
(952) 


J 


OPERATIONS   UPON   THE  LIPS  AND    CHEEK.      953 

In  making  up  the  sum  of  an  operation,  the  operator  is  to  con- 
sider, regai'dless  of  the  age  of  the  patient,  the  amount  of  shock  such 

can  put  the  parts  then  neatly  together,  and  you  can  almost  answer  positively 
for  the  union  taking  place.  I  operated,"  continues  this  gentleman,  "  on  a 
child,  the  other  day,  in  whom  the  operation  had  been  performed  twelve 
months  ago.  The  parents  were  anxious  to  have  it  performed,  but  I  then  re- 
fused ;it  was  done,  however;  but  the  moment  the  pins  were  removed,  the 
lip  turned  out  as  before." 

"  For  my  own  part,"  says  Mr.  Bransby  Cooper,  "  I  entirely  agree  with  Sir 
Astley  Cooper,  in  regarding  it  as  unsafe  to  operate  on  infants  before  weaning  : 
first,  because,  from  their  excessive  irritability,  they  are  totally  unable  to  sus- 
tain any  loss  of  blood;  and  secondly,  because,  after  the  operation,  they  are 
rendered  incapable  of  sucking;  and,  indeed,  Sir  Astley  has  pointed  out,  in 
his  lectures,  the  frequency  of  the  failures  he  met  with  in  his  own  practice, 
in  operating  upon  infants  shortly  after  birth.  I  consider  the  best  time,  under 
ordinary  circumstances,  to  be  soon  after  the  child  is  weaned,  as  it  is  then 
capable  of  receiving  nourishment  independently  of  its  mother,  and  has  over- 
come the  distress  incidental  to  the  separation  from  her." 

Dr.  Houston,  of  London,  in  examining  the  question  as  to  the  period  of  life 
best  fitted  for  the  performance  of  the  operation,  decides  in  favor  of  the  third 
month  after  birth  ;  urging,  as  his  reasons,  that  the  parts  recover  themselves 
better  than  when  the  operation  is  performed  later  in  life  ;  that  the  lip  in  due 
time  acquires  fullness  and  pliancy  ;  the  nose  is  prevented  from  assuming  a 
spread-out,  ugly  appearance  ;  the  fissure  in  the  palate,  if  there  be  any,  closes 
greatly  with  the  growth,  if  supported  by  a  firm  and  perfect  lip  ;  bad  habits 
of  speaking,  such  as  guttural  or  nasal  utterance,  which  if  once  established 
become  irremediable,  are  avoided;  and  by  removing  the  disfiguration  before 
the  child  is  conscious  of  its  existence,  it  is  spared  the  feelings  of  humiliation 
which  the  consciousness  of  such  an  infirmity  necessarily  imparts,  and  which 
invariably  gives  a  tone  to  the  character  of  the  individual.  He  states  that  he 
has  operated  on  several  infants  three  months  old,  with  equal  success  in  all 
cases,  and  has  never  failed. 

Dupuytren  recommends  the  third  month  ;  Yelpeau,  the  first  six;  but  if 
that  be  alread}'  passed,  he  defers  operating  until  the  tenth  or  fifteenth  year. 

Skey,  difi'oring  from  Velpeau,  says,  "The  operation  may  be  performed  at 
almost  any  age,  but  should  not  be  undertaken  under  about  six  months." 

"The  period  of  life,"  says  Mr.  Fergusson,  "  which  I  think  very  eligible 
for  these  operations,  is  either  before  the  teeth  begin  to  show  through  the  gums, 
or  shortly  after  the  child  has  ceased  to  suck,  provided  the  health  seems  good. 
If  the  patient  is  allowed  to  grow  up,  he  is  usually  unmanageable  until  after 
the  age  of  puberty  ;  but,  if  possible,  the  malformation  should  always  be  put 
right  before  this  time,  as  there  is  a  better  chance  of  the  gum  and  nose  as- 
suming a  good  shape  than  after  they  have  arrived  at  their  full  development. 
Indeed,"  continues  Mr.  Fergusson,  "  there  are  so  many  advantages  besides 
these — as  to  speaking,  appearance,  etc. — that  it  is  wonderful  any  surgeon  can 
recommend  delay  in  such  cases  after  the  first  or  second  year  of  life.     I  have 


954  ORAL  DISEASES  AND  SURGERY. 

operation  is  to  give,  and  the  ability  of  the  patient  to  bear  this  shock. 
This  at  once  brings  up  the  character  of  the  defect,  and  the  amount 

myself,''  says  Mr.  Fcrgusson,  "operated  frequentlj-  within  the  first  three 
months,  and  in  some  of  these  instances  seen  the  child  take  the  breast  readily, 
with  the  pins  still  in  the  lip.'' 

Dr.  J.  Mason  Warren  has  operated  on  infants  only  a  few  days  old,  with 
perfect  success.  Professor  P.  Dubois  read  before  the  Academy  of  Medicine 
of  Paris  a  paper  on  this  subject,  and  referred  to  seven  instances  which  had 
come  under  his  notice,  where  the  proceedings  had  been  resorted  to,  and  suc- 
cessfullj',  within  the  first  few  days  after  birth  ;  and  Malgaigne  has  followed 
a  similar  practice. 

"  From  all  my  experience  and  reflections,"  deduces  Mr.  Fergusson,  "  I  am 
more  than  ever  disposed  to  recommend  a  very  early  operation.  Within  the 
last  twelve  months  I  have  operated  on  five  infants,  all  of  them  under  three 
months,  with  the  most  satisfactory  results  ;  and  these  cases,  with  others  I  have 
previouslj'  had,  are  sufficient  to  induce  me  to  pursue  a  similar  practice  in  all 
instances  of  the  kind  which  may  come  under  my  notice,  unless  there  be  some 
apparent  indication  not  to  interfere.  An  erroneous  impression,  as  I  suppose, 
prevails  that  children  are  remarkably  subject  to  convulsions  while  undergoim;- 
operations  ;  and  this  is  often  urged  as  a  reason  for  not  interfering  with  a  hare- 
lip in  early  life.  Doubtless  convulsions  have  occurred  in  some  of  these  cases; 
but  similar  effects  have  been  produced  in  the  adult,  and  by  less  formidable 
means,  too.  Sir  Astley  Cooper  has  referred  to  several  examples  of  this  kind, 
but  I  imagine  they  must  be  rare  indeed.  I  once  asked  Dr.  Abercrombie,  of 
Edinburgh,  the  result  of  his  experience  on  this  point,  and  he  could  not  bring 
a  single  instance  to  his  recollection  where  convulsions  could  be  fairly  attrib- 
uted to  an  operation." 

'•  At  what  period,"  says  CoUes,  the  famous  Dublin  professor,  "  should  one 
undertake  the  operation  for  hare-lip?  No  doubt  the  earlier  you  perform  it 
the  better  chance  you  will  have  of  a  speedy  cure ;  but  infants  at  a  very  early 
age  do  not  bear  operations  well  ;  many  of  them  will  be  seized  with  convul- 
sions, and  die,  if  subjected  to  a  more  trifling  operation  than  this  we  have 
been  considering.  I  think  between  the  second  and  third  year  is  the  best 
period." 

Prof.  D.  H.  Agnew  operates  at  any  period  :  is  influenced  only,  even  during 
the  process  of  dentition,  by  constitutional  condition.  If  dentition  is  pro- 
gressing quietly,  that  is,  if  there  is  no  associated  irritability,  he  can  see  no 
reason  whj^  the  operation  may  not  be  performed  just  as  well  at  this  time  as  at 
any  other  ;  has  operated  in  all  the  stages  of  this  process.  Dr.  Agnew  prefers, 
however,  early  operations  ;  he  thinks  that  his  most  successful  cases  have  been 
on  children  who  had  not  attained  their  tenth  day.  So  far  as  interference 
with  sucking  is  concerned,  he  remarks  that  he  has  seen  a  child  take  the  breast 
almost  immediately  after  an  operation  has  been  completed. 

Professor  Pancoast  entertains  about  the  same  views  as  are  expressed  by  Dr. 
Agnew.  Dr.  Pancoast  gives  it  as  the  result  of  his  very  extended  experience, 
that  tlie  operation  may  be  about  as  well  done  at  one  time  as  at  another: 


J 


OPERATIONS    UPON   THE  LIPS  AND    CHEEK.      955 

of  operative  proceeding  necessary  to  its  cure.  A  bad  double  cleft 
would  inflict  a  much  greater  amount  of  pain  than  a  simple  single 
one,  and  consequently  would  inflict  a  shock  double  or  treble  in  force 
to  the  last.  Now,  every  man,  woman,"  and  child  in  the  woi-ld  has  a 
certain  amount  of  physique,  and  no  more.  The  experience  and  phy- 
siological knowledge  of  the  surgeon  should  enable  him  to  weigh 
this  life-force.  He  must  then  decide,  in  the  first  place,  whether  or 
not  his  patient  is  equal  in  such  force  to  the  demands  of  a  proposed 
operation.  He  must  consider  the  condition  of  his  patient.  This 
brings  up  the  second  of  the  special  propositions  or  stand-points  from 
which  the  operation  is  to  be  studied.  The  possession  of  a  capable 
physique  does  not  imply  that  the  life-force  has  not,  like  the  tide,  its  ebb 
and  flow.  A  child  may  have  proper  development,  yet  at  the  very 
time  when  it  is  presented  for  operation  it  may  labor  under  temporary 
depression,  the  result,  perhaps,  of  functional  disturbances.  A  child, 
for  example,  just  convalescent  from  cholera  infantum,  or  just  recovered 
from  some  of  the  exanthemata,  would  certainly  not  be  so  fit  a  sub- 
does  not  see  why  the  period  of  dentition  is  to  he  so  cautiously  avoided  ; 
operates  at  any  period  of  this  process,  if  there  are  no  contra-indications  of 
constitutional  disturbance  ;  has  operated  on  many  children  as  early  as  a  few 
days  after  birth,  with  the  happiest  results  ;  does  not  find  the  operation  inter- 
fere materially  with  nursing. 

Professor  Henry  H.  Smith,  of  the  University  of  Pennsj-lvania,  says,  "As 
respects  the  period  for  the  operation,  the  earliest  possible  time  after  the  tissues 
seem  firm  is  to  be  selected,  usually  after  the  third  month  of  infancy." 

Now,  although  I  have  here  cited  such  a  variety  of  opinions,  which,  to  the 
inexperienced,  may  seem  confusing,  j'et,  when  we  consider  the  different 
circumstances  under  which  these  learned  and  experienced  gentlemen  have 
written  and  spoken,  we  are  enabled  to  deduce  from  such  experiences  rules  for 
guidance,  in  which,  if  my  observation  at  all  serves  me,  will  be  found  data  as 
reliable  as  we  could  well  expect  to  possess.  The  views  of  such  as  I  have  men- 
tioned will  be  found  to  represent  fairly  the  diversity  of  opinion  existing 
throughout  the  profession.  These  well-known  authorities  have  been  especi- 
ally selected,  because,  being  public  teachers  and  writers,  their  views  in  extenso 
are  thereby  made  the  more  easy  to  come  at  by  any  reader  specially  interested 
in  this  subject. 

The  author,  who  has  operated  upon  such  number  and  conditions  of  hare- 
lip as  to  give  him  full  confidence  in  his  own  experience,  prefers  that  period 
which  precedes  the  eruption  of  the  first  teeth.  In  babes  of  such  age,  he  has 
frequently  been  able  to  remove  the  first  pin  in  twenty-four  hours,  and  the 
remainder  at  the  end  of  the  second  day.  Any  time,  then,  he  would  say, 
between  the  fourth  week  and  sixth  month  is  to  be  considered  the  period  of 
selection.  The  operation,  however,  may  be  performed  at  any  time,  (bee 
text.) 


956  ORAL   DISEASES  AND   SURGERT. 

ject  fov  operation  as  though  it  bad  not  suffered  ;  it  may  have  borne 
the  demands  made  upon  it  very  well,  and  come  out  of  the  ordeal 
looking  strong  ;  but  then  it  is  the  last  feather  that  breaks  the  camel's 
back;  the  system  that  endured  bravely  the  one  demand  may  not  have 
a  residue  of  force  on  hand  that  will  just  then  meet  another.  Give 
such  a  system  time  ;  get  it  back  to  the  condition  in  which  the  first 
demand  found  it,  and  you  then  have  it  certainly  capable  of  the  same 
resistance  and  of  the  same  endurance.  Again,  a  patient  may  not  be 
up  to  the  required  tone,  and  yet  circumstances  may  render  a  speedy 
operation  desirable.  We  can  assist  nature.  Exercise,  fresh  air,  and 
proper  food  can  do  much.  The  last  may  imply  that  the  milk  of  the 
mother,  if  the  child  be  nursing,  be  exchanged  for  that  of  the  hired 
nurse.  Who  has  not  examined  the  milk  of  a  mother  or  wet-nurse 
and  found  it  greatly  deficient  in  some  important  constituent?  The 
author  has  seen  b<abes  growing  weaker  and  more  puny  day  by  day; 
has  seen  physicians  baffled  because  they  could  find  no  one  portion  of 
the  economy  less  healthy  than  another.  He  has  seen  the  microscopist 
take  the  milk  on  which  such  a  babe  has  been  feeding,  and,  looking 
at  it  through  his  glasses,  find  large  quantities  of  colostrum.  A 
change  of  milk  has  eS"ected  an  immediate  change  in  the  health  of  the 
child.  A  child  may  have  fibrinous  blood  to  excess,  tending  to  undue 
circulatory  excitement,  or  the  lymph  which  such  blood  would  exude 
might  be  so  corpuscular  in  character  that  a  wound  would  at  once 
take  on  suppurative  action.  Either  condition  would  be  adverse  to 
an  operation.  Yet  we  have  alteratives  for  the  one,  and  tonics  for 
the  other.  A  seemingly  strong  child  may  be  in  a  typhoid  state, 
and  a  blushing  cheek  may  be  but  the  eff"ect  of  hectic  or  excitement; 
typhoid  blood  has,  comparatively,  no  fibrin.  If  you  were  to  perform 
an  operation  on  a  patient  so  conditioned,  you  would  be  sure  to  have 
a  failure  for  your  pains.  The  writer  has  h;id  under  care  patients  in 
just  such  a  typhoid  state;  the  pulse  would  be  bounding  iind  the  face 
always  flushed:  such  a  quick  pulse  and  flush  is,  however,  the  result 
of  the  very  deficiency  in  the  blood.  A  child  may  be  cutting  its 
teeth,  yet  this  does  not  necessarily  contra-indicate  an  operation.  It 
is  not  every  child  that  has  convulsions  and  kindred  troubles  with 
the  cutting  of  its  teeth  ;  many  an  infant  goes  through  the  whole  pro- 
cess of  dentition  without  cause  upon  which  to  ground  a  sob.  If  a 
child  is  brought  to  the  surgeon,  cutting  teeth,  with  an  operation  for 
hare-lip  to  be  performed,  and  there  is  associated  with  the  dentition 
no  general  or  special  local  disturbance,  why  should  be  not  proceed, 
caeteris  parihuii,  at  once  to  operate?  There  are  no  objections  to  so 
doinsr. 


OPEEATIONS   UPON   THE  LIPS  AND    CHEEK.      957 

The  next  consideration  is  the  operation  itself, — the  modification& 
of  the  one  principal  operation,  and  the  variety  of  clefts  influencing 
such  modifications. 

A  basis  operation  mig-ht  best  be  represented  by  a  simple  V-cleft, 
having  the  mesiau  line  of  the  lip  as  its  centre, — the  indication  being 
to  restore  such  lip  to  a  normal  con- 
tour. (See  Fig.  299.)   On  examination,  Fig.  299. 
we  find  that  a  normal  lip  has  no  break 
in  its  continuity  ;  we  find  what  mny 
be  termed  the'centre  of  the  lip  repre- 
sented at  its  free  margin  by  a  projec- 
tion of  more  or  less  graceful  curve. 
We    find,    extending   from    this   free 
margin  up  to  the  nares,  and  bounded      E'"pt''^*i  '"^i^'>"" '"  t'-"  -p^'-''''-"  ^"^ 
laterally  by  the  alse  nasi,  a  fossa, — 

the  fossa  labialis.  From  this  fossa  we  find  the  lip  on  either  side 
spreading  itself  out  to  be  lost  in  the  cheek.  To  meet  the  indications 
of  this  case  we  must  remedy  the  break  in  the  continuity,  create  a 
mesial  projection,  and  give  to  the  centre  a  fossa.  To  fulfill  such 
indications  requires  a  study  of  the  conditions  from  a  surgico-artistic 
stand-point.  We  want,  first,  to  correct  the  cleft.  This  in  itself  is 
easy  of  accomplishment ;  we  have  only  to  pare  the  edges  and  sew,, 
or  pin,  the  raw  surfaces  together.  But  in  viewing  this  first  stej)  a 
little  more  closely,  we  perceive  that  a  common  V-paring  from  tlie 
edges  of  the  Y-break  would  defeat  our  purpose  in  securing  either 
a  centre  fossa  or  a  mesial  projection  ;  the  mode  of  bringing  the  parts 
together  would  put  on  the  stretch  such  fibres  of  the  orbicular  muscle 
as  are  associated  with  the  margin  of  the  lip,  while  all  that  portion 
farther  up  would  be  comparatively  relaxed ;  thus  our  fossa  would 
be  a  promontory,  and  our  soft  median  swell  would  be  a  stretched 
raucous  membrane.  Such  an  operation  would,  then,  in  meeting  the 
first  indication,  destroy  our  ability  to  fulfill  the  two  others.  We 
must,  therefore,  instead  of  the  V-cut,  seek  a  better  ;  for  on  the  way 
in  which  we  pare  our  edges  depends  the  fulfillment  of  all  three  of 
the  indications.  An  ellipse  suggests  itself,  and  such  a  paring  will^ 
measurably,  meet  our  wants.  1st.  It  enables  us  to  bring  the  edges 
of  the  cleft  together.  2d.  The  centre  of  the  ellipse  is  its  greatest 
diameter,  and  this  centre  is  the  centre  of  the  lip.  When  we  bring 
together  this  most  widely  separated  part,  it  necessarily  projects  the 
most  yielding  surface — and  such  surface  is  the  free  symphysis  of  the 
lip ;  thus  the  second  indication  is  met.     3d.  The  greatest  stretch  on 


958  ORAL  DISEASES  AND   SURGERY. 

the  muscle  is  in  the  site  of  the  myrtiform  fossa,  with  a  necessary 
relaxation  above  and  below ;  and  thus  the  last  indication  is  met ; 
for,  as  the  result  of  such  a  condition  of  the  parts,  we  have  a  fossa 
formed  and  a  promontory  at  the  free  mesial  line. 

Remarks. — The  paring  of  a  cleft  should  always  be  constant  in  the 
one  feature  of  being  Y-shaped,  as  reference  is  had  to  the  base  of  the 
V  looking  toward  the  throat ;  this  allows  for  excess  in  the  retrac- 
tion of  the  skin  over  the  mucous  membrane.  If  this  precaution  is 
neglected,  a  difficulty  is  likely  to  be  experienced  in  the  gaping  of  the 
cutaneous  portion  of  the  wound. 

The  subject  of  retaining  the  parts  in  apposition,  with  regard 
to  suture  material,  has  elicited  much  controversy.  The  ordinary 
operation  is  as  follows.  After  3'ou  have  pared  the  edges  of  the  cleft, 
take  up  a  needle  threaded  with  the  ordinary  waxed  silk,  pass  this 
through  the  free  margins  of  the  lip  and  bring  the  parts  together; 
this  is  to  insure  a  satisfactory  approximation  at  this  point.  Next 
take  two  ordinary  steel  i)ins  and  pass  them  at  equidistant  points  on 
the  lip, — they  must  go,  in  depth,  at  least  half  its  thickness;  these 
pins  are  to  enter  and  emerge  at  least  five  lines  on  each  side  of  the 
fissure.  Silk  ligature  stufl",  in  the  .shape  of  the  figure-of-8,  is  now 
to  be  passed  about  and  around  these  pin.s.  (See  Plate  IX.,  Fig.  5.) 
Adhesive  strips  are  next  passed  over  the  pins,  a  slit  being  made  for 
their  accommodation  ;  the  object  of  these  strips  is  to  press  tissue 
toward  the  wound,  preventing,  through  such  support,  undue  tension. 
If  blood  oozes  out  and  clots  upon  the  ligatures,  it  has  been  considered 
rather  favorable  than  otherwise,  as  it  has  been  thought  to  add  to  the 
support  of  the  parts.  After  two  or  three  days  the  pins  are  carefully 
removed  by  a  rotatory  motion;  the  ligature  material  and  adhesive 
strips  are  allowed  to  remain  from  four  days  to  a  week  longer. 

Various  means  have  been  suggested  to  be  employed  in  lieu  of  the 
pin  and  figure-of-8  dressing,  objection  to  such  dressing  certainly  ex- 
isting in  ulceration  apt  to  associate  with  the  pressure  induced  by 
swelling.  Prof.  Agnew  uses  silver  wire.  He  simply  sews  the  parts 
together  with  a  greater  or  loss  number  of  interrupted  sutures.  He 
thinks  such  sutures  possess  great  advantages  over  the  pins. 

Another  means  of  bringing  the  parts  together  which  has  been 
suggested,  consists  in  the  employment  of  the  interrupted  suture  of 
silk  used  from  the  under  surface  of  the  lip.  In  such  use  of  the  hid- 
den suture  nice  approximation  and  support  arc  to  be  given  the  face 
of  the  wound. 

Dr.  Washington  Atlee  has  suggested  a  suture  which  dififers  only 


\ 


OPERATIOXS    UP  OX   THE  LIPS  AND    CHEEK.      959 

from  the  ordinary  pin  and  figure-of-8  in  that  he  employs  rings  of 
india-rubber,  which  are  stretched  over  the  pins.  This  suture  for 
many  purposes  must  prove  an  admirable  addition  to  the  armamenta- 
rium chirurgicum  ;  but  in  hare-lip  operations  it  has  no  advantage 
over  the  ordinary  figure-of-8,  inasmuch  as  the  same  strain,  if  not  a 
greater,  is  exerted  upon  the  points  at  which  the  rubber  is  supported 
by  the  pins.  The  merit  claimed  for  this  suture  is,  that  whether  a 
part  swells  or  remains  normal,  the  compressing  force  continues  about 
the  same. 

A  mode  of  securing  the  apposition  of  the  parts,  which  will  be 
found  very  satisfactory,  is  to  take  three,  four,  or  more  threads  of 
silver  wire, — the  fewer  you  can  get  along  with  the  better, — the  gauge 
being  the  most  delicate  that  can  be  procured;  pass  these  and  let 
them  emerge  at  lines  which  shall  very  nearly  correspond  with  the 
commissure  of  the  lips.  jS'ext  take  a  strip  of  common  sheet-lead, 
and,  cutting  it  to  an  appropriate  size,  make  in  it  as  many  little  holes 
as  you  have  threads  to  either  side ;  pass  the  threads  through 
these  holes,  and  compress  on  each  a  McLeon  button — i.e.  a  simple 
flat  shot.  ]N'ow,  with  the  fingers,  nicely  approximate  the  wound. 
This  satisfactorily  accomplished,  draw  up  the  wires  and  fix  them  on 
a  second  piece  of  sheet-lead,  as  in  the  first  instance.  If  the  centre, 
which  is  the  line  of  the  wound,  tends  to  bulge  forward,  a  delicate 
compress  is  to  be  placed  over  it,  and  bound  to  its  place  by  an  adhe- 
sive strip.  The  advantages  of  this  dressing  are,  that  it  may  be 
retained  for  weeks,  if  necessary;  it  is  entirely  unirritating;  the 
wound  is  perfectly  open  to  examination  ;  and,  more  than  all  this,  the 
threads,  being  unirritating  and  very  slight,  when  taken  away  leave 
no  scars. 

A  still  happier  dressing,  but  one  which  can  be  applied  only  on 
such  patients  as  have  reached  the  age  of  intelligence,  is  a  modifica- 
tion on  Dewar's  dressing.  Hainsby's  compressor  may  be  likened 
to  the  ordinary  double  hernia  truss.  It  consists  simply  of  a  spring 
which  passes  around  the  head,  having  a  small  pad  at  each  extremity. 
The  piece  is  of  such  circle  and  character  as  to  bring  the  pads  to  the 
labial  commissures.  The  instrument  is  held  in  position  by  any  con- 
venient means.  Dewar  holds  it  by  what  might  be  termed  a  fronto- 
sagitto-lambdoidal  sling.  The  process  of  dressing  with  this  instru- 
ment would  be  as  follows.  After  making  the  paring  of  the  cleft, 
cleanse  the  parts  well  with  cold  water  (controlling  hemorrhage  by 
pressure  on  the  facial  arteries) ;  next  take  a  strand  of  the  common 
silk  ligature  material,  and  nicely  approximate  the  free  edges  of  the 


960 


ORAL  DISEASES  AND  SURGERY 


lip,  passing  the  needle  on  the  under  side.  The  next  step  is  the 
application  of  the  compressor.  With  the  thumb  and  finger  now  force 
the  tissue  of  the  cheeks  toward  the  mesial  line  of  the  lip — this  ap- 
proximates perfectly  the  edges  of  the  wound ;  replace  your  fingers 
by  the  compressor,  and  the  parts  are  held  in  situ.  If  the  approxi- 
mation of  the  wound  thus  made  should  not,  however,  be  satisfactory, 
secondary  compresses  of  linen  may  be  placed  more  immediately 

Fir;   300. — Haixsby's  Compressor. 


about  the  wound,  aud  fixed  by  a  delicate  roller.  The  advantages  of 
this  dressing  will  be  at  once  apparent.  There  are  no  pins  or  liga- 
tures used,  consequently  there  is  nothing  to  interfere  with  direct 
union  ;  there  are  no  punctures  made  in  the  skin  ;  of  course  there  is 
no  risk  of  having  any  but  the  single  linear  scar,  and  even  this,  if 
direct  union  is  secured,  must  be  slight  indeed.  The  parts  can  be 
examined  at  any  time  without  important  interference  with  the 
apparatus.* 

In  some  individuals  the  coronary  arteries  are  quite  large.  To 
suppress  the  hemorrhage  from  these  vessels,  dependence  is  generally 
placed  on  the  pressure  exerted  in  bringing  together  the  edges  of  the 


*  This  description  does  not,  as  is  seen,  accord  fully  with  the  diagram  ;  the 
pin  and  figure-of-8  being  shown.  The  drawing  has  been  utilized  to  show  the 
feature  of  the  ordinary  dressing. 


OPERATIONS    UPON  THE  LIPS  AND   CHEEK.      961 

wound.  If  such  pressure  does  not  answer,  or  if  we  should  prefer 
some  dressing  that  will  not  make  this  pressure,  light  ligatures  may- 
be thrown  around  the  vessels,  one  end  to  be  cut  oflf,  the  other  to  be 
brought  out  at  the  back  part  of  the  wound.  Ligatures,  however, 
are  to  be  avoided  when  possible,  as  they  interfere  with  proper 
union. 

A  much  better  means  than  the  resort  to  the  ligature  is  compres- 
sion of  the  facial  arteries.  Such  compression  needs  to  be  kept  up 
but  for  a  short  time,  as  the  smaller  vessels  soon  contract.  Hainsby's 
compress  controls  the  hemorrhage  by  its  pressure  on  the  coronary 
arteries,  and  its  action  may  be  very  readily  imitated  with  a  common 
compress  and  roller. 

There  is  a  feature  associated  with  the  formation  of  the  linear 
cicatrix,  and  the  unsightly  notch  which  so  commonly  deforms  hare- 
lip patients,  that  I  do  not  remember  to  have  ever  seen  alluded  to, 
but  which  is  of  such  consequence  as  to  merit  the  closest  scrutiny. 
Is  it  the  fault  of  nature  or  the  fault  of  the  surgeon  that  the  opera- 
tion gives  any  cicatrix  at  all  ?  Cicatricial  tissue — tissu  inodulaire, 
as  Delpech  more  happily  terms  it — means  accidental  tissue,^ — new 
tissue  formed  from  granulations.  The  existence  of  inodular  tissue 
implies,  as  it  is  greater  or  less  in  amount,  that  a  wound  has  healed 
either  by  primary  or  secondary  adhesion,  and  certainly  not  by  what 
Mr.  Hunter  terms  union  by  first  intention,  or  what  Mr.  Paget  calls 
immediate  union.  If  a  wound  is  made  to  unite  by  first  intention, 
there  cannot  possibly  be  any  observable  inodular  tissue  or  scar,  be- 
cause so  little  new  tissue  has  been  formed,  blood-vessels  and  nerves 
have  been  brought  into  perfect  contact,  and  the  harmony  of  the  parts 
has  been  so  completely  restored  that  after  a  few  weeks  the  closest 
observation  fails  to  discover  the  seat  of  accident.  We  have  familiar 
examples  of  such  union  in  the  slight  cuts  we  are  constantly  giving 
ourselves  with  the  razor,  the  cuts  we  get  about  the  fingers,  etc. 
Some  years  back  the  author  removed  from  the  parotid  region  of  a 
young  man  a  tumor  fully  the  size  of  a  hen's  e^^.  The  flaps  were 
adjusted  with  the  greatest  care,  and  held  in  place  by  compresses  of 
old  and  fine  linen.  Ten  weeks  after  the  operation  the  union  was 
found  to  be  so  immediate  that  it  was  impossible  to  say  where  the 
cut  had  been  made.* 

The  union  of  a  wound  by  adhesion  or  by  granulation  implies  a 


*  Mr.  Paget  mentions  very  large  wounds  that  not  unfreqiiently  heal  in  this 
perfect  manner.     One  case,  that  of  a  lady  who  had  been  operated  on  for  scir- 

60 


962  ORAL  DISEASES  AND  SURGERY. 

certain  amount  of  inflammatory  action,  and  the  exudation  and 
organization  of  lymph.  This  is  the  way  in  which  hare-lip  wounds 
are  healed,  and  this  is  why  we  have  the  linear  cicatrix ;  and  not  only 
the  cicatrix,  but,  according  as  the  union  has  simulated  or  departed 
from  the  immediate  type,  we  have  necessarily  a  great  or  a  small 
notch. 

But  how  is  the  notch  formed  ?  The  explanation  is  simple  enough ; 
but  it  is  not  that  generally  given  ;  at  least,  I  think  not.  The  notch 
is  the  result  of  the  natural  contraction  which  belongs  to  fibrous 
tissue,  of  which  fibrous  tissue  the  cicatrix  is  formed ;  and  if  we  ob- 
serve, we  will  find  that  where  this  linear  inodular  tissue  exists  in 
excess,  a  large  notch  is  always  associated  with  it.  If  we  need 
further  proof  to  convince  ourselves  that  such  contraction  is  the 
cause  of  the  notch,  we  have  only  to  remark  that  in  cases  of  large 
cicatrices  the  destruction  of  the  symmetry  of  all  the  surrounding 
parts  has  invariably  occurred  ;  the  contraction  has  puckered,  as  it 
were,  the  whole  part.  When  a  linear  cicatrix  is  very  limited,  the 
notch  is  correspondingly  small ;  and  these  conditions  could  not  so 

rhus  of  the  mammary  gland,  might  be  specially  alluded  to.  Speaking  of  the 
operation,  he  says, — 

"  The  flaps,  which  were  very  large,  had  been  carefully  laid  down,  strapped 
with  isinglass  plaster,  and  well  tended.  After  death,  which  occurred  in  three 
weeks,  from  erysipelas  and  phlebitis,  I  cut  off  the  edges  of  the  wound  with 
the  subjacent  parts,  expecting  to  find  the  evidences  of  union  by  organized 
lymph,  or,  possibly,  blood  ;  but  neither  existed  ;  and  the  state  of  the  parts 
cannot  be  better  described  than  by  saying  that  scarcely  the  least  indication 
remained  of  either  the  place  where  the  flap  of  skin  was  laid  on  the  fascia,  or 
the  means  by  which  thoy  were  united.  It  was  not  possible  to  distinguish  the 
relation  which  these  parts  held  to  each  other  from  that  which  naturally  exists 
between  subcutaneous  fat  and  the  fat  beneath  it.  There  was  no  unnatural 
adhesion  ;  but  the  subcutaneous  fat  which  did  lie  over  the  mammary  gland 
was  now  connected  with  the  fascia  over  the  pectoral  muscle.  The  parts  were 
altered  in  their  relations,  but  not  in  their  structure.  I  could  find,"  con- 
tinues Mr.  Paget,  "  small  points  of  induration  where,  I  suspect,  ligatures 
had  been  tied,  or  where  possibly  some  slight  inflammation  had  been  other- 
wise excited  ;  and  one  small  abscess  existed  under  the  lower  flap.  But,  with 
the  most  careful  microscopic  examination,  I  could  discover  no  lymph  or 
exudation  corpuscles,  and  only  a  small  quantity  of  what  looked  like  the 
debris  of  such  oil  particles  or  corpuscles  of  blood  as  might  have  been  between 
the  cut  surfaces  when  the  flaps  were  laid  down.  In  short,"  says  Mr.  Paget, 
*'this  was  union  by  first  intention;  it  was  immediate,  at  once  in  respect  of 
the  absence  of  any  intermediate  substance  placed  between  the  wounded  sur- 
faces, and  in  respect  of  the  speed  with  which  it  was  accomplished." 


OPERATIONS    UPON   THE  LIPS  AND    CHEEK.      963 

uniformly  exist  associated,  if  it  was  the  manner  of  the  paring  ex- 
clusively that  gave  the  notch,  and  not  the  contraction,  as  described. 

The  nearer,  then,  the  approach  to  a  union  by  first  intention  we 
can  make  in  hare-lip,  the  better  for  our  success  will  be  the  result. 
But  can  we  not  get  immediate  union  in  full  ?  This  would  imply 
that  we  have  artery  to  artery,  vein  to  vein,  nerve  to  nerve.  Well, 
the  artery  is  a  prominent  point  of  reference,  and  the  relations  of 
surrounding  parts  are  in  perfect  unison.  If  we  can  get  the  mouths 
of  the  two  arteries  together,  will  not  all  other  vessels  assume,  by 
compulsion,  inosculation  ?  We  may  try  for  this,  at  any  rate ;  such 
care  will  necessarily  insure  to  us  the  very  nicest  approximation  of 
parts,  and,  if  what  is  termed  immediate  union  cannot  be  obtained, 
we  may  at  least  secure  to  our  patient,  by  such  care,  the  smallest 
possible  scar.  To  secure  the  most  perfect  union,  a  wound  should 
never  be  approximated  until  all  hemorrhage  has  ceased  and  the  raw 
surface  becomes  glazed  with  a  film  of  lymph. 

Fig.  301  represents  a  modification  in  the  ordinary  operation  for 
simple  hare-lip  which  the  author  has  now  performed  many  times, 
and  always  with  the  most  satisfactory  success.  This  operation,  as 
is  seen,  differs  from  that  shown  in  the  preceding  figure  in  having 

Fig.  301. 


the  parings  utilized  in  place  of  being  cut  away.  Studying  the  dia- 
gram, it  is  seen  that  the  parings,  being  commenced  at  the  nasal 
septum,  have  been  cut  to  the  free  border  of  the  lip,  from  which,  sup- 
ported by  their  attachment,  they  hang.  From  the  septum  to  the 
apices  of  the  flaps  it  is  seen  that  raw  surfaces  approximate :  the 
parts  in  this  condition  are  now  brought  and  retained  in  apposition, 


964 


ORAL  DISEASES  AND  SURGERY. 


Fig.  302. 


the  pendent  portion  being  trimmed  to  that  shape  which  considers  the 
labial  swell.     This  operation  performed,  a  notch  cannot  result. 
A  second  modification  on  the  basal  operation  is  shown  in  Fig. 

302.  Here,  as  is  seen,  one  side 
of  the  break  (the  left)  is  most 
extensively  pared,  the  section 
taking  off  quite  a  portion  of  the 
free  border  of  the  lip.  Upon 
the  opposite  side,  however,  the 
paring  is  compensatory.  Study 
of  the  section  will  exhibit  that 
the  flap  of  the  right  side  restores 
the  removed  part  on  the  left,  af- 
fording, at  the  same  time,  com- 
plete continuity  of  the  free  border 
of  the  lip  at  the  mesian  line. 


Complications. — The  first  modification  of  the  simple  mesian  cleft, 
which  has  been  described  as  a  type,  is  where  the  break  is  to  the  one 
side  or  other  of  the  labial  centre,  this  centre  constituting  one  of  the 
lateral  boundaries.  This  character  of  cleft,  particularly  so  far  as 
the  left  side  is  concerned,  is  by  far  the  most  common  form  ;  indeed, 
it  is  to  be  denominated  the  type  proper  of  hare-lip. 

In  operating  on  a  case  of  single  break,  laterally  related,  as  thus 
described,  certain  variations,  as  must  be  seen,  are  demanded.  Em- 
ploying the  ellipse,  it  is  recognized  that  the  labial  prominence  would 
necessarily  be  thrown  out  of  that  exact  mesial  position  which  is  its 
place.  The  same  defect  would  reside  in  uniform  pendent  parings.  To 
meet  the  objections,  using  the  ellipse,  a  modification,  as  practiced 
by  Malgaigne,  is  employed.  This  surgeon  makes  the  one  side  of  a 
simple  Y-cut  upon  the  outer  flap ;  upon  the  mesian  is  practiced  the 
ellipse.  The  bringing  together  of  two  surfaces  so  related  throws 
down,  as  is  seen,  the  free  border  of  the  mesian  flap. 

A  modification  on  the  operation  of  the  French  surgeon,  suggested, 
I  believe,  by  Dr.  Richard  Levis,  consists  in  making  a  double  V  on 
the  mesian  flap;  entering  the  knife  just  below  the  nostril,  a  first  inci- 
sion pares  the  flap  ;  a  second  now  removes  from  this  surface  a  small 
Y-shaped  piece,  having  its  apex  looking  toward  the  cheek.  In  bring- 
ing the  parts  together,  which  is  done  by  inserting  a  pin  at  the  apex 
of  the  second  Y  and  passing  it  through  the  opposite  flap,  it  is  seen 
that  the  free  border  of  the  mesian  flap  is  alike  bulged  downward. 


OPERATIONS   UPON   THE  LIPS  AND    CHEEK.      965 

Better,  however,  than  the  operations  either  of  Malgaigne  or  of  Dr. 
Levis,  is  a  modification  on  the  operation  shown  in  Fig.  301 ;  this, 
however,  being  on  a  precisely  similar  principle,  the  paring  from  the 
mesian  flap  being  to  such  extent  heavier  than  its  fellow,  as  shall 
place  the  desired  prominence  in  its  right  position. 

Another  variety  in  hare-lip,  and  the  next  most  common,  is  that  in 
which  the  break  is  double, — that  is,  the  single  break  is  divided  into 
two  parts  by  a  teat  which  starts  out  from  the  apex  of  the  cleft ;  this 
teat  is  seldom  more  than  half  the  width  of  the  lip.  Fig.  303,  kindly 
furnished  the  author  by  Dr.  Harrison  Allen,  being  a  case  from  his 
practice,  exhibits  very  satisfactorily  an 
example  of   the   most   simple   of  such  ■^^°-  ^^^• 

double  breaks.  A  second  is  shown  in 
Plate  IX.,  Fig.  4.  For  the  correction 
of  this  defect,  various  means  are  re- 
sorted to.  Some  surgeons  cut  out  the 
teat,  thus  converting  the  double  into  a 
single  break,  making  the  basis  cleft  as 
described.  Others,  on  the  contrary,  after 

paring  all  the  four  sides,  tease  and  strain  the  centre  piece  or  teat  until 
they  get  it  on  a  level  with  the  rest  of  the  lip.  Both  of  these  opera- 
tions are  very  objectionable.  The  first  takes  away  an  unnecessary 
amount  of  substance  from  the  lip,  thus  giving  a  tense,  stretched 
appearance  to  the  part,  while,  from  the  second  manipulation,  the 
natural  resiliency  which  belongs  to  most  tissue  compels  a  character 
of  notch  or  central  depression  almost  as  unsightly  as  the  original 
deformity.  In  this  simple  form  of  double  hare-lip  it  will  be  found 
the  most  satisfactory  operation  to  pare  the  lateral  flaps  in  the  form 
as  shown  in  Fig.  301,  while  the  centre  teat  should  be  pared  into 
the  T-form,  the  base  being  to  the  septum  narium;  all  the  parts  will 
thus  be  found  capable  of  a  neat  approximation,  the  teat  doing  its 
share  more  or  less  in  filling  up  the  break.  The  approximation  is 
to  be  made  in  the  mode  described. 

A  second  form  of  double  hare-lip  is  that  in  which  the  alveolar 
process  is  associated  with  the  teat.  This  is  termed  complicated 
bare-lip.  The  portion  of  process  projecting  into  the  cleft  is  gen- 
erally an  intermaxillary  formation,  and  holds  the  germs  or  developed 
incisor  teeth.  The  correction  of  this  defect  implies  a  somewhat 
formidable  operation.  The  first  step  consists  in  separating  well  the 
lip  from  its  reflection  over  the  process,  should  attachment  exist. 
Next  the  gum  is  separated  thoroughly  from  the  projecting  bone, 


966  ORAL  DISEASES  AND  SURGERY. 

which  bone  the  third  step  in  the  operation  removes  down  to  the  natu- 
ral curvature  of  the  parts,  this  last  being  effected  either  by  means 
of  saw,  chisel,  or  cutting  forceps.  For  myself,  I  prefer  the  cutting 
forceps ;  it  is  certainly  a  much  more  convenient  instrument  than  the 
Hey's  saw  so  commonly  employed.  A  straight  and  a  curved  chisel 
should  also  always  be  at  hand.  If  in  this  third  step  of  the  operation 
the  anterior  palatine  artery  be  wounded,  the  resulting  hemorrhage  is 
easily  controlled,  either  by  taking  up  the  vessel  or  by  touching  it 
with  one  of  the  astringents  ;  or,  if  neither  of  these  means  suffices 
for  its  accomplishment,  the  artery  may  be  touched  Avith  a  red-hot 
cauterant  needle,  or,  better,  it  may  be  plugged  with  a  point  of  pine 
stick.  The  bone  removed,  the  flaps  of  gum  may  be  laid  back  in  the 
cavity,  where  they  will  remain  sufficiently  approximated  without  the 
employment  of  any  sutures.  The  operation  upon  the  lip  may  now  be 
performed  at  once  in  any  of  the  manners  described ;  or,  if  the  force  of 
the  patient  be  too  much  exhausted,  it  may  be  left  for  a  future  period. 
These  are  the  two  principal  forms  of  double  hare-lip.  An  appre- 
ciation of  the  operaliofis  required  for  their  cure  will  enable  the  sur- 
geon to  meet  satisfactorily  any  modifications  that  may  present  on 
either  of  them  ;  and  these  modifications,  it  is  to  be  suggested,  are 
constantly  occurring.  Let  us,  for  a  single  moment,  refer  to  an  un- 
complicated double  hare-lip,  where  the  centre  piece,  or  teat,  as  it  is 
called,  might  be  found  so  large  and  square  as  fairly  to  divide  the 
lip  into  three  parts.  Now,  here  the  mesian  line  of  the  lip  would  be 
found  in  the  centre  piece ;  it  would  therefore  suggest  itself  to  any 
one  that  either  side  of  the  cleft  was  to  be  treated  as  a  separate  hare- 
lip— that  is,  the  whole  manipulation  might  be  done  at  the  one  sitting; 
but  there  would  have  to  be  symmetrical  parings  made  of  either  cleft. 
In  such  a  case,  we  have  also  to  take  into  account  the  concavity 
made  on  either  side  of  our  fissure,  as  reference  is  had  to  the  influ- 
ence exerted  on  the  free  margin  of  the  lip  ;  for  here  of  course  we 
require  no  swell.  Whether,  again,  in  these  really  double  cases, 
we  would  first  operate  on  the  one  side,  and,  when  this  was  cured, 
on  the  other,  is  a  matter  which  is  to  be  decided  by  the  judgment  of 
the  operator.  Many  surgeons  pi'efer  to  correct  the  whole  deformity 
at  once.  If  it  should  be  decided  to  do  this,  the  operation  would  only 
deviate  from  the  principles  laid  down,  as  regard  would  be  had  to 
approximating  the  parts.  If  the  centre  piece  be  small,  it  will  be 
found  the  most  satisfactory  practice  to  pass  the  pins,  wire,  or  what- 
ever suture  material  is  used,  directly  from  one  lateral  flap,  on  through 
the  centre  piece,  to  and  through  the  other,  thus  uniting  all  the  parts 


I 


OPERATIONS   UPON  THE  LIPS  AND    CHEEK.      9QJ 

together  by  a  common  suture.  If,  on  the  contrary,  a  centre  piece  is 
broad  and  well  covered  by  skin,  the  greatest  uood  is  found  in  using 
two  sets  of  ligatures.  As  regards  the  single  or  double  operation, 
the  author  is  influenced  by  the  width  of  the  middle  piece,  the  tense- 
ness or  laxity  of  the  tissue  of  the  lip,  and  the  endurance  and  condi- 
tion of  the  patient. 

A  modification  of  the  double  hare-lip  is  one  in  which  there  is  a 
projection,  into  the  cleft,  of  the  incisor  teeth  ;  the  alveolar  process 
itself  being  sufficiently  normal  to  allow  of  non-interference  with  it. 
This  modification  is  commonly  met  with  in  the  adult  alone,  or  at 
least  after  second  dentition.  The  projection  of  the  teeth  is  the 
natural  result  of  the  lack  of  external  support  from  the  labial  defi- 
ciency; the  tongue  has  actually  pushed  them  outwardly.  This 
explanation  will  seem  strange  only  to  such  as  are  unacquainted  with 
the  exceeding  mobility  of  the  dental  organs  under  slight  but  con- 
tinued force.  It  is  certainly  the  true  cause  of  such  projection.  In 
a  case  of  this  kind,  a  preliminary  operation  is  the  removal  of  the 
teeth.  If,  now,  six  months  be  allowed  to  intervene  before  attempt- 
ing the  operation  on  the  lip,  the  alveoli  of  the  extracted  teeth  will 
be  found  to  have  receded,  through  absorption,  quite  the  eighth  of  an 
inch.  The  second  operation  is  then  to  be  done  secundum  artem. 
This  waiting  on  the  process  of  absorption  will  be  found  greatly  to 
conduce  to  a  successful  result. 

A  still  better,  though  a  more  tedious,  mode  of  correcting  such  a 
deformity  is  by  first  bringing  the  projecting  teeth  back  to  their 
normal  place  in  the  arch,  through  the  agency  of  elastic  ligatures. 
This  is  a  perfectly  feasible  operation,  and  not  at  all  difficult  of  per- 
formance. By  such  a  preliminary  procedure  we  not  only  get  the 
teeth  out  of  the  way,  but  we  save  to  the  patient  these  valuable 
organs.  To  make  and  apply  such  a  ligature,  we  have  only  to  take 
a  slip  of  common  india-rubber  and  attach  at  each  end  a  loop  of  silk. 
We  next  place  these  loops  over  certain  of  the  molar  teeth  ;  it  is  entirely 
immaterial  which :  the  centre,  or  rubber  part,  is  then  stretched  forward 
and  laid  over  the  labial  faces  of  the  teeth  to  be  pulled  back.  It  is 
astonishing  how  quickly  and  powerfully  such  a  force  will  act  upon 
the  teeth.  In  two  or  three  weeks,  at  most,  the  oi-gans  may  be  brought 
into  their  proper  line.  To  secure  them  in  situ,  and  prevent  their  being 
again  pushed  forward,  we  have  only  to  keep  them  ligatured  in  any 
convenient  manner  until  the  operation  on  the  lip  is  made,  and  union 
secured. 

Cleft  of  the  lip,  as  previously  remarked,  is  common  to  perhaps  a 


968  ORAL  DISEASES  AND  SUBGERT. 

majority  of  the  cases  of  cleft  of  the  hard  palate.  It  has  always 
been  deemed  very  important  in  these  cases  that  an  operation  on  the 
lip  should  be  performed  as  early  as  possible;  it  is  thought  to  favor 
approximation  in  the  bony  cleft.  In  these  cases  the  operation 
differs  from  that  suited  to  any  ordinary  one  only  when  there  is  pro- 
jection of  one  or  both  alveolar  prominences  into  the  break.*  In 
such  instances,  if  the  projection  be  very  marked — that  is,  so  much 
80  as  to  prevent  the  bringing  together  of  the  lips — we  may  perhaps 
be  able  to  do  nothing  better  than  cut  away  the  parts.  This,  how- 
ever, is  always  to  be  avoided  where  possible :  first,  because  thus 
we  destroy  the  germs  of  the  teeth ;  and,  secondly,  because,  if  by 
any  means  we  can  get  union  of  the  lip,  the  parts  in  their  develop- 
ment will  come  mutually  to  accommodate  themselves  to  each  other. 
In  such  cases  it  is  recommended  by  some  authors  that  we  endeavor  to 
bend  back  these  juttings  of  bone,  turning  them  in  toward  the  mesial 
line.  Where  this  can  be  done,  it  answers  a  very  admirable  purpose. 
Still  another  mode — after  the  method  suggested  for  the  complete  re- 
lief of  this  character  of  cleft — consists  in  the  employment  of  the  frouto- 
occipito-labial  elastic  sling.  This  sling  is  so  applied  that  it  pulls 
from  the  occiput  upon  the  projecting  process.  It  will  certainly  fulfill 
the  indications ;  but  its  employment  is  not  unattended  with  trouble. 

Cases  of  double  hare-lip  not  unfrequently  occur  where  the  centre 
slip  is  so  associated  with  the  septum  of  the  nares  as  to  make  the 
parts  seem  as  one:  if  there  was  not  the  loss  of  material  from  the  lip, 
the  septum  would  bear  being  described  as  in  a  state  of  hypertrophy. 
-Again,  the  lost  part  from  the  lip  is  sometimes  found  attached  to  the 
very  tip  of  the  nose,  giving  to  the  patient  somewhat  the  appearance  of 
laboring  under  lipoma.  These,  together  with  all  the  anomalies  in  this 
direction,  are  first  to  be  studied,  as  regards  their  cure,  from  the  artistic 
stand-point.  The  surgeon  knows  where  and  what  he  can  afford  to 
cut ;  he  judges  what  nature  will  do  in  the  case  ;  it  only  remains  for 
him  to  consider  well  his  incisions,  where  he  shall  make  them,  and 
what  is  to  be  the  artistic  result,  before  the  operation  is  attempted. 

A  useful  stud}^  is  found  in  the  examination  of  examples.  If  we 
familiarize  ourselves  with  all  kinds  of  cases,  and  if — what  is  commonly 
found  more  at  command — we  represent  the  morbid  anatomy  in  india- 
rubber,  and  thus  devise  and  try  experimental  operations,  we  shall,  I 
am  sure,  find  the  subject  of  hare-lip  grow  simple  enough. 

Addenda. — In  operating  for  hare-lip,  always  first  dissect  the  lip 
well  off  from  its  attachment  to  the  gum. 

*  See  Cleft  Palate. 


OPERATIONS    UPON  THE  LIPS  AND    CHEEK.      969 

In  paring  the  fissures,  the  young  surgeon  is  much  more  apt  to 
remove  too  little  than  too  much. 

In  paring  out  the  apex  of  the  cleft,  be  sure  to  freshen  perfectly 
the  extreme  point  of  such  apex.  This  is  oftentimes  neglected ;  and 
an  ugly  pucker  is  the  result. 

The  paring  for  hare-lip  is,  perhaps,  best  made  on  a  wooden  spatula. 

Few  instruments  are  really  required  in  this  operation.  A  scalpel 
and  forceps,  together  with  such  ligature  material  as  it  is  designed  to 
employ,  will  answer  the  purpose  well  enough. 

A  mode  of  operating  on  the  infant  is  for  the  surgeon  to  seat 
himself  face  to  face  with  an  assistant.  The  child  being  etherized, 
the  surgeon  lays  its  body  over  his  own  knees,  the  head  being 
supported  by  the  assistant.  Upon  the  incision  being  made  on  one 
side,  the  assistant  grasps  the  lip  between  the  thumb  and  finger, 
compressing  the  coronary  artery.  When  the  artery  of  the  opposite 
side  is  cut,  he  secures  this.  Both  are  steadily  held  until  the  oper- 
ator is  ready  to  coaptate  the  wound. 

In  operatiug  on  the  adult,  I  think  it  will  be  found  the  most  con- 
venient plan  to  stand  behind  the  patient;  such  a  chair  being  used, 
and  the  head  being  placed  in  such  position,  as  recommended  in  the 
operation  of  staphyloraphy. 

Another  very  convenient  manner  is  to  sit  in  front  of  the  patient," 
the  head  being  supported  against  the  breast  of  an  assistant. 

When  plaster  is  used  to  assist  the  ligatures,  silk  gauze  and  collo- 
dion are  to  be  preferred ;  this  leaves  the  wound  constantly  exposed 
to  inspection,  and  is  a  light  and  most  effective  dressing. 

STUDIES  IN   COMPLICATED   HARE-LIP. 

Fig.  304  is  a  dissection  showing  the  nature  and  character  of  the 
intermaxillary   projection.       Where   such  p^^  ^^^ 

bone  interferes  with  the  ability  to  obliterate 
the  cleft,  it  is  plainly  seen  that  it  may  be 
cut  away. 

Figs.  305,  306,  307,  and  308,  which  are 
strictly  true  to  cases  constantly  being  met 
with,  exhibit  aspects  of  intermaxillary 
complication.  Wherever  such  intermediate 
projections  are  found  unyielding,  and  may 
not  as  soft  tissue  be  utilized,  the  author 
pursues  the  practice  of  cutting  the  parts 
away:  this  converts  the  case  at  once  into  single  hare-lip,  with  the 


970 


ORAL  DISEASES  AND  SURGERY. 


complication,  however,  of  a  very  great  loss  of  substance  from  the 
centre  of  the  lip  ;  this  may  not  be  helped  ;  and  if  the  parts  are  found 


Fig.  305. 


Fig.  30G. 


too  widely  apart  to  be  brought  together,  as  directed  in  the  ordinary 
cases,  the  operator  may  be  compelled  to  resort  to  the  cheeks  for  the 
required  material.     (See  Making  Upper  Lip.) 


Fig.  30'; 


Fig.  308. 


Fig.  309,  being  from  life,  represents  the  appearance  of  a  child 
operated  on  by  the  author  at  one  of  his  late  clinics.  In  this  case 
complete  cleft  existed  not  only  in  the  lip  but  in  both  hard  and  soft 
palates,  while  pendent  from  the  nasal  septum  was  a  mass  half  car- 
tilage, half  bone,  which,  as  shown  in  the  drawing,  was  the  complete 
representation,  in  shape,  of  a  door-knob. 

In  examining  this  case,  it  will  be  seen  that  the  removal  of  the 
pendent  mass  might  be  in  a  moment  effected  by  section  of  the 


'J 

I 


OPERATIONS    UPON   THE  LIPS  AND    CHEEK.      971 

pedicle.  This  was  done,  exposing  now  fully  the  cleft  in  the  lip, 
which,  as  is  recognized,  was  very  extensive.  To  make  raw  and 
bring  the  boundaries  of  this  cleft  in  apposition  was  now  the  indica- 
tion.     This  was  accomplished  after  the  manner  of  utilizing  the 

Fig.  309. 


parings;  the  strain  on  the  pins,  however,  being  very  great,  extra 
support  was  given  by  placing  a  roll  on  either  side  and  dragging  all 
the  lateral  aspect  of  the  parts  toward  the  mesial  line  by  means  of 
adhesive  strips. 

In  this  case  the  strain  on  the  pins  necessitated  their  removal 
earlier  than  was  desirable;  but  moderate  union  was  found  to  have 
been  secured  at  the  free  border  of  the  lip, — that  is,  with  the  parings. 
Taking  advantage  of  this,  support  was  kept  up  by  means  of  the 
extemporized  Hainsby's  compress,  and  after  two  weeks  the  cleft 
was  found  obliterated,  having  been  filled  up  by  granulation. 

This  case  is  selected  as  an  example,  because  it  is  an  instance 
where  nothing  better  might  have  been  done  than  the  operation 
practiced,  the  child  not  having  force  to  endure  a  more  complicated 
means  of  treatment.  It  was  not  desirable  to  have  a  cure  by  gran- 
ulation ;  but  it  was  better  than  taking  risks  overbalancing  the  good 
to  be  secured. 

Fig.  3,  Plate  IX.,  exhibits  the  manner  of  placing  a  pin. 

Fig.  5  exhibits  three  pins  in  place,  the  points  being  cut  off,  and 
the  parts  retained  in  apposition  by  means  of  the  figure-of-8. 

Fig.  6  exhibits  the  dressing  of  a  simple,  uncomplicated  double 
hare-lip. 

Pins. — Until  very  familiar  with  the  operation,  it  is  advised  that 
in  approximating  flaps  the  ordinary  steel  or  gold  pin  be  used.  Such 


972 


ORAL  DISEASES  AND  SURGERY. 


means,  while  having  the  objections  noticed,  will  yet  be  found  of 
most  ready  and  convenient  application. 

In  passing  a  pin,  it  is  to  be  carried  forward  until  within  about 
three  lines  of  the  head. 

In  casting  the  figui*e-of-8,  no  more  strain  is  to  be  employed  than 
suffices  simply  to  hold  the  denuded  surfaces  in  contact;  more  than 
this  is  almost  sure  to  result  in  strangulation  of  the  compressed  parts, 
and  consequent  ulceration  marking  the  line  of  the  pins. 

Pins  are  always  to  be  removed  as  quickly  as  the  parts  are  found 
sufficiently  self-supporting,  their  presence  interfering  necessarily 
with  the  process  of  union. 

In  withdrawing  a  pin,  support  is  demanded  by  the  lip.  A  rude 
removal  is  apt  to  tear  asunder  the  delicate  granulations. 

Fig.  310. 


Fig.  310  exhibits  the  twisted  or  hare-lip  suture,  together  with 
the  manner  of  making  it. 


CHAPTER    XLYII. 

OPERATIONS   UPON   THE    LIPS   AND    CHEEK. 

As  the  result  of  disease  or  accident,  persons  occasionally  suffer 
from  contraction  of  the  orifice  of  the  mouth, — a  most  unhappy  con- 
dition, both  as  regards  the  appearance  and  the  comfort  of  the 
individual.  Such  contractions  are  represented  in  Plate  IX.,  Figs. 
7,  8,  and  9. 

Dieffenbach,  of  Berlin,  who  interested  himself  very  much  in  the 
surgery  of  the  mouth,  suggested  and  practiced  for  the  relief  of  these 
deformities  an  operation,  which,  with  occasional  slight  and  unim- 
portant modifications,  is  the  one  still  generally  employed. 

Dieffenbach's  operation  is  performed  on  the  following  principles : 
Map  out  with  pen  and  ink  on  the  tissues  such  lines  and  angles  as 
shall  meet  your  approbation  of  what  the  proper  mouth  should  be. 
These  lines  are,  of  course,  to  be  in  conjunction  with  the  existing 
orifice  or  commissure,  wherever  or  however  situated, — that  is,  the 
relation  of  the  existing  orifice  must  be  studied  as  it  is  to  have 
association  with  the  cuts  you  are  to  make.  Thus,  glancing  at 
Pig.  t,  we  at  once  appreciate  the  necessity  for  enlarging  the  mouth 
by  sections  equilateral  to  the  centre,  as  certainly  it  is  apparent 
enough  that  only  by  such  a  form  of  incision — which  I  have  caused 
to  be  represented  by  a  line — could  we  secure  the  end  at  which  we 
aim.  Fig.  8,  on  the  contrary,  would  demand  an  operation  exclu- 
sively lateral ;  for  here  the  mouth  at  its  right  angle  is  as  perfect  as 
we  could  hope  to  make  it.  Fig.  9  presents  us  with  a  complication 
on  these  simple  conditions.  These  complications  might  be  multi- 
plied almost  indefinitely;  for  who  may  say  in  what  condition  a 
wound  or  other  injury  shall  leave  a  part?  At  any  rate,  the  surgeon 
is  to  be  prepared  to  meet  all  kinds  of  modifications.  These 
three  figures  give,  however,  as  just  an  idea  of  the  mechanico- 
surgical  indications  of  such  cases  as  any  others  that  might  be 
drawn.     Figs.  1  and  8  are  from  life  ;  9  is  one  made  up  to  represent 

(973) 


974  ORAL  DISEASES  AND   SURGERY. 

a  not  unlikely  aspect.*  It  exhibits,  as  is  seen,  a  combination  of  a 
cicatrix  and  hare-lip.  In  this  last  case  is  suggested  of  itself  the 
necessity  for  a  double  operation.  The  mouth  is  to  be  made  smaller 
before  it  would  be  at  all  proper  to  attempt  making  it  larger.  We 
must  first  perform  a  hare-lip  operation.  Imagine  this  done,  and 
then  further  the  condition  in  which  such  operation  would  leave  the 
orifice.  If  we  refer  to  the  drawing,  we  see  that  the  opening  is  now 
at  what  is  properly  the  right  angle  of  the  mouth ;  and  an  operation 
for  the  making  of  a  proper  commissure,  if  there  was  no  hare-  or 
cleft-lip,  would  be  precisely  the  same  lateral  incision  as  that  indi- 
cated in  Case  8.  But  then  it  is  to  be  remarked  that,  after  the  first 
operation  was  performed,  the  orifice  would  not  be,  as  now,  at  the 
proper  right  angle.  The  bringing  of  the  cleft  together  would  pull 
it  naturally  toward  the  mesial  line.  Thus,  then,  it  is  made  a  cross 
between  T  and  8;  it  is  not  like  7,  because  it  is  not  exactly  in  the 
mesial  line,  and  it  would  not  be  like  8,  because  it  has  been  drawn 
from  the  proper  right  angle  toward  the  mesial  line.  Here,  then,  the 
complication  has  materially  changed  the  indications  of  the  principal 
operation.  The  incisions  would  have  to  be  bilateral,  but  yet  not 
equally  so  as  reference  is  had  to  the  false  commissural  centre,  but 
only  as  reference  would  be  made,  say  to  the  septum  narium  or  any 
other  fixed  mesial  line  proper.  The  space  between  the  central 
incisor  teeth  would  be  a  good  mesial  centre  to  take. 

These  features  well  considered,  we  take  up  a  pair  of  sharp-pointed 
scissors,  and,  passing  a  finger  of  the  left  hand  into  the  mouth,  enter 
one  blade  of  the  scissors  down  through  the  tissues  toward  the 
finger,  sparing  alone  in  the  puncture  the  mucous  membrane;  the 
blade  is  now  pushed  forward  toward  the  mesial  line,  and  the  tissues 
incised,  as  indicated  by  the  superior  right  lateral  half  of  the  ellipse 
represented  by  the  line  in  Fig.  7.  The  scissors  are  now  reintro- 
duced at  the  previous  point  of  entrance,  and  the  cut  made  on  the 
inferior  lip  precisely  as  was  done  above.  Next  dissect  out  the 
triangular  piece.  Repeat  these  incisions  on  the  opposite  side.  The 
next  step  considers  the  incision  of  the  mucous  membrane.  This  is 
done  simply  by  dividing  it  down  the  centre  to  within  two  or  three 
lines  of  the  angle  of  the  wound  ;  it  is  then  to  be  brought  over  the 
cut  surfaces  and  attached  by  means  of  the  interrupted  suture  to 
the  skin. 

*  Fig.  9  is  not  correct  to  the  text :  add  to  it  the  defect  in  Fig.  1,  and  it  will 
be  right. 


OPERATIONS   UPON  THE  LIPS  AND   CHEEK.     975 

This  mode  of  re-establishing  the  orifice  of  the  mouth  is  thought 
by  many  surgeons  to  be  the  best  that  can  be  employed.  Prof. 
Smith,  of  the  University,  reports  two  cases  operated  on  after  this 
method,  which  resulted,  he  says,  to  his  entire  satisfaction. 

The  late  Prof.  Miitter  reports  similar  satisfactory  results.* 


*  Dr.  Mutter's  Case. — The  patient  was  a  daughter  of  a  respectable  practi- 
tioner of  medicine  residing  in  South  Carolina,  and,  at  the  time  the  accident 
productive  of  the  deformity  occurred,  was  about  eleven  years  of  age ;  of  fine 
general  health,  though  of  a  temperament  strongly  lymphatic. 

In  the  commencement  of  the  winter  of  1835,  while  at  play  with  her  com- 
panions, she  was  by  some  means  or  other  thrust  against  a  heated  stove,  by 
which  her  hands,  arms,  nock,  and  the  lower  part  of  her  face  were  severely 
burned. 

Her  wounds  were  treated  in  a  most  judicious  manner  by  her  father  ;■  but, 
in  spite  of  all  his  eflForts,  those  about  the  mouth  cicatrized  with  so  much  con- 
traction that  the  entrance  into  this  cavity  was  almost  obliterated.  As  soon 
as  the  tenderness  of  the  part  was  somewhat  diminished,  he  commenced  a 
course  of  treatment  calculated  to  restore  this  orifice  to  its  natural  size.  He 
first  began  by  introducing  sponge  tents,  which  were  allowed  fully  to  distend 
themselves ;  but,  after  repeated  attempts  with  them,  bj'  which  he  caused  the 
child  much  suffering  without  materially  benefiting  her,  they  were  abandoned. 

He  then  attempted  to  dilate  it  by  first  making  an  incision  about  six  lines 
in  length,  extending  from  each  angle  of  the  mouth  in  an  outward  and  nearly 
horizontal  direction,  and  afterward  introducing  the  tents  to  prevent  the  lips 
of  the  wound  from  uniting.  This  appeared  at  first  to  be  productive  of  some 
good ;  but  in  a  short  time  they  contracted  and  cicatrized,  and  the  patient 
remained  in  as  uncomfortable  a  condition  as  before. 

Finding  himself  foiled  in  both  attempts,  he  determined  to  bring  her  to 
Philadelphia  for  the  purpose  of  consultation.  She  was  accordingly  brought 
on,  and  became  a  patient  of  Professor  Miitter,  who  says,  "  When  I  first  saw 
her,  nearly  a  year  had  elapsed  since  the  occurrence  of  the  accident.  Her 
appearance  at  the  time  was  very  singular.  Firm  and  dense  cicatrices  nearly 
surrounded  the  mouth,  but  were  most  marked  on  the  lower  lip  and  about  the 
angles,  while  the  orifice  of  this  cavity  was  barely  large  enough  to  admit  the 
point  of  the  finger,  and  presented  an  oval  form.  The  cicatrices  of  the  incis- 
ions made  by  her  father  were  also  very  apparent  at  each  angle.  Her  general 
health  was  perfect ;  and  it  was  only  on  account  of  the  deformity  and  difiiculty 
of  taking  her  food  that  the  operation  was  requested.  Her  speech  was  not 
much  affected,  although  some  of  the  labial  sounds  were  imperfectly  pro- 
nounced.    The  lining  membrane  of  the  mouth  was  perfectly  normal." 

"  From  the  history  of  the  case,"  says  Prof.  M.,  "I  concluded  it  would  be 
utterly  useless  to  attempt  a  cure  by  the  repetition  of  the  measures  already 
employed,  and  which  are  the  only  ones  usually  had  recourse  to.  I  therefore 
proposed  the  operation  devised  by  Dieffenbach,  and,  her  father  consenting, 
it  was  accordingly  performed  on  the  28th  of  the  month  of  consultation. 

"  The  operation   completed,  a  common  roller  bandage  was  applied,  as  in 


976  ORAL  DISEASES  AND  SURGERY. 

A  modification  of  the  mode  of  DiefiFenbach,  which  I  would  sug- 
gest, and  which  I  am  confident  will  yield  still  better  results,  is  aa 
association  with  these  surgical  means  of  a  mechanical  appliance. 

cases  of  fracture  of  the  lower  jaw,  in  order  to  prevent  any  derangement  of 
the  wounds.  The  patient  was  then  placed  in  bed,  with  her  head  elevated, 
and,  as  she  had  just  before  the  operation  eaten  freely  of  some  light  food, 
ordered  to  take  no  nourishment  of  any  kind  until  the  next  visit,  and  to  be 
perfectly  silent. 

"  29th.  Passed  a  good  night ;  slept  well  ;  no  fever,  and  complains  of  no 
pain  ;  parts  merely  a  little  sore ;  needles  all  in  place ;  writes  that  she  is 
hungry.  Ordered  thin  oat-meal  gruel  as  diet,  which,  as  well  as  her  drink, 
is  to  be  given  with  a  small  teaspoon. 

"30th.  Quite  as  well  as  yesterday;  everything  in  place;  bowels  costive; 
ordered  an  injection  of  white  soap  and  water;  diet  as  before. 

"31st.  Complains  of  stiffness  in  the  wounds,  but  no  pain;  dressing  all 
secured;  injection  had  operated  well ;  pulse  natural;  ordered  chicken  soup 
for  diet. 

''Dec.  1st.  The  bandages  were  removed,  and  the  first  dressing  commenced. 
The  sutures,  which  had  been  closely  bound  down  to  the  parts  by  blood,  were 
carefully  softened  with  warm  water  and  cut  away.  As  soon  as  they  were 
removed,  and  the  parts  properly  dried,  the  most  gratifying  exhibition  of  the 
success  of  the  operation  was  afforded.  On  both  sides,  union  between  the 
everted  mucous  membranfe  and  the  margins  of  the  wounds  had  taken  place 
nearly  throughout,  and  the  new  lips  presented  an  appearance  almost  natural. 
Some  of  the  needles  were  then  removed  ;  but,  as  there  appeared  to  be  a 
feebleness  in  the  adhesion  at  some  points,  the  needles  passing  through  them 
were  allowed  to  remain,  and  a  thread  cast  loosely  around  them.  The  bandage 
around  the  head  was  also  reapplied. 

"2d.  Second  dressing,  parts;  all  firm  and  healthy;  the  remaining  needles 
were  now  removed,  and  the  bandages  only  reapplied,  which  was  done  to 
prevent  talking ;  no  pain  in  the  part,  and  the  patient  in  fine  spirits.  Ordered 
bowels  to  be  opened  with  an  injection,  and  the  diet  to  be  more  nutritious,  but 
still  liquid. 

"  Nothing  remarkable  occurred  in  the  subsequent  treatment ;  all  dressings 
were  taken  off  on  the  15th,  and  the  child  allowed  to  pursue  her  ordinary 
course  of  life.  The  mouth  presented  a  verj^  good  appearance,  though  the  lips 
were  somewhat  thinner  than  natural,  and  there  was  some  difficulty  in  bring- 
ing them  in  close  contact,  especially  at  the  central  portions." 

Mr.  Liston  reports  a  case  of  equal  interest.  Mrs.  H.,  aged  twenty-two, 
was  knocked  down  in  a  brawl,  and  a  man  jumped  upon  her,  lacerating  and 
bruising  her  cheek  and  mouth  extensively,  and  fracturing  her  jaw.  She 
went  to  St.  Thomas's  Hospital,  where  her  jaw  was  put  up  and  bandaged. 
These  were  not  removed  for  some  time  ;  and,  when  taken  off,  the  wound  on 
the  right  side  of  the  mouth  was  found  healed,  and  the  cicatrix  considerably 
contracted  ;  since  then  the  contraction  has  continued  somewhat,  and  now  is 
so  small  that  she  can  scarcely  get  any  solid  food  to  pass  her  lips.     There  is  a 


OPERATIONS   UPON   THE  LIPS  AND    CHEEK.      977 

After  the  operation,  as  described,  has  been  performed,  and  time 
has  been  given  for  union  of  the  reflected  mucous  membrane,  let  such 

large,  dense,  white  cicatrix  on  the  right  side  of  the  mouth,  rather  jiuckered, 
and  sharp  toward  the  angle  of  the  mouth.  An  operation  was  performed  on 
the  23d.  Mr.  Liston  removed  a  triangular  portion  of  the  cicatri.x;  on  the  right 
side  of  the  mouth,  dissecting  it  oft'  the  mucous  membrane,  which  was  then 
divided  to  the  extent  of  the  external  wound.  Lint  dipped  in  cold  water  was 
then  laid  over  the  surface  to  suppress  the  oozing  of  blood,  which  was  by  no 
means  considerable.  About  five  hours  after  the  operation,  all  oozing  having 
ceased,  the  mucous  membrane  was  turned  over  the  cut  edge  of  the  cicatrix, 
and  united  by  three  or  four  points  of  suture  to  the  skin  of  the  cheek ;  by  this 
means  a  mucous  surface  was  secured  to  the  newly-formed  prohibium,  and  the 
gradual  cicatrization  and  consequent  contraction  dispensed  with. 

History  of  the  case,  from  notes  : 

24th.  A  little  swelling  around  the  wound  ;  not  much  pain. 

25th.  The  sutures  were  removed  to-day.  Adhesion  appears  to  have  taken 
place  between  the  mucous  membrane  and  skin.  Water  dressing  to  be  applied 
to  the  lips. 

Nov.  1st.  The  water  dressing  has  been  continued;  union  between  the  mucous 
membrane  and  skin  took  place  to  a  considerable  extent  by  the  first  intention. 
The  remaining  parts  are  granulating  favorably.  The  mouth  is  much  improved 
in  appearance  and  usefulness. 

4th.  The  lip  nearly  healed,  only  a  small  sore  remaining  in  the  lower  lip. 
Eed  wash  dressing  to  be  applied  to  it.     Discharged  much  relieved. 

A  case  operated  on  by  the  author  at  his  clinic,  which  resulted  entirely  satis- 
factorily, will  be  found  in  the  Keports  of  Dr.  De  Forrest  Willard. 

"The  subjoined  case  illustrates  a  successful  operation  under  circum- 
stances of  unusual  difficulty.  The  deformity  was  of  old  standing,  and  the 
parts  had  sufi'ered  from  several  outbreaks  of  disease  and  ulcerative  action  ; 
the  mouth  and  parts  around  had  now  been  the  seat  for  many  months  of  lupoid 
ulceration,  mixed  with  a  syphilitic  taint,  which  had  caused,  in  the  process  of 
cicatrization,  great  condensation  of  the  lips  and  cheeks  generally,  and  adhe- 
sions between  the  cheek  and  the  gum  of  the  upper  jaw.  The  mouth  was 
reduced  to  the  smallest  dimensions,  and  would  absolutely  not  admit  the  point 
of  the  little  finger;  there  was  also  a  hardened  papillary  growth  on  the  lower 
lip.  The  patient  had  not  taken  any  solids  for  months,  and  had  to  use  a  kind 
of  little  ramrod  to  introduce  his  food  through  the  narrowed  and  immovable 
opening.  His  speech  was  necessarily  imperfect,  and  any  continued  conversa- 
tion impracticable.  The  patient  was  thirty-five  years  of  age,  much  broken 
down  in  health  and  spirits,  and  urgently  sought  relief  from  the  gradual 
narrowing  of  the  orifice  and  from  the  ulceration  which  still  existed. 

"  He  had  suflered  from  exfoliations  of  the  forehead  and  osteoscojnc  pains, 
and  the  tongue  was  painful  fi-om  ulcerations,  which  could  not  be  treated  by 
any  ordinary  local  stimulation. 

"  Large  doses  of  iodide  of  potassium  were  administered  ;  a  tongue-bath  of 
black-wash,  used  twice  daily,  and  good  diet  ordered. 

61 


978 


ORAL  DISEASES  AND  SURGERY. 


an  appliance  as  is  here  figured  (mouth-stretcher,  it  might  be  called) 
be  prepared,  and  slip  it  between  the  lips.     This  stretcher  represents 


Fro.  311. 


a  propcr]\'-shaped  mouth  ;  the  li{)s  in  the  whole  of  their  circumfer- 
ences are  caught  and  held  by  the  gutter  of  the  apparatus,  and  thus 
not  only  is  the  healing  influenced  to  a  desired  shape,  but  undue 
cicatricial  contraction  is  prevented. 

"  After  five  weeks  the  ulceration  of  the  lips  and  mouth  had  much  improved, 
and  when  the  healing  process  had  completed  itself  I  adopted  the  following 
procedure  in  order  to  insure  as  much  as  possible  against  contraction.  I 
passed  a  full-sized  Chassaignac's  drainage-tube  through  the  cheek,  about 
three-quarters  of  an  inch  from  the  angle  of  the  contracted  mouth,  and  re- 
tained the  tube  in  this  position,  acting  as  an  issue  till  cicatrization  had  taken 
place  around,  and  a  tistulous  orifice,  in  fact,  formed  :  this  occupied  about 
fourteen  daj's  in  its  production.  I  then  frum  this  point  carried  two  incisions 
toward  the  mouth,  and  removed  a  ratlier  wedge-shaped  piece,  its  apex  being 
at  the  fistulous  opening  produced.  This  was  followed  bj'a  satisfactory  result  ; 
the  parts  gradually  healed,  but  some  contraction  nevertheless  occurred  to 
about  one-half  When  this  side  was  tolerably  healed  I  adopted  a  similar 
proceeding  at  the  other,  but  I  took  care  to  increase  the  distance  from  the 
angle  of  the  mouth  ;  after  fourteen  days,  when  I  found  the  tubing  had  suffi- 
ciently established  a  fistula,  I  took  away  also  a  wedge-shaped  piece,  as  at  the 
other  side,  and  adopted  every  precaution  to  prevent  further  narrowing.  I 
gained  on  this  side  more  than  half  the  distance.  The  mobility  of  the  jaws 
was  perfect ;  the  patient  had  lost  many  of  the  teeth  b}'  ulceration  of  the  alveoli, 
and  the  integument  over  the  chin  was  drawn  as  tightly  as  it  is  possible  to 
conceive. 

"  The  comparative  illustrations  of  the  condition  before  and  after  operation 
will  show  the  gi-eat  narrowing  that  had  taken  place,  combined  with  increased 
density,  almost  of  a  cartilaginous  firmness,  and  tlie  imjirovemcnt  gained. 

"  The  repair  of  the  general  health,  and  the  rapidity  with  which  he  regained 
his  weight  and  strength,  were  remarkable  in  this  patient ;  he  felt  so  strong 
shortly  after  being  operated  on  as  to  leave  hospital'and  go  to  work. 

"The  use  of  the  tubing,  and  the  formation  of  a  fistulous  point  to  act  from 
and  insure  a  permanent  angle  to  the  lips,  I  found  most  satisfactory  as  the  main 
cause  of  a  perfect  result  to  the  patient ;  the  tendency  to  contract  and  curtail 
the  natural  opening  was  most  persistent." — Mr.  Morrison,  F.K. C.S.I. 


OPEBATIONS    UPON   THE  LIPS  AND    CHEEK.      O79 

If  it  is  objected  that  such  an  instrument  would  look  ungainly  in 
the  mouth,  I  have  only  to  answer  that  after  the  Grst  week  or  two 
there  would  exist  no  occasion  for  its  constant  wearing;  it  might  be 
entirely  dispensed  with  during  the  day  and  be  worn  only  at  night. 
Such  use  of  it,  however,  should  be  continued  at  least  six  months,  if 
we  would  have  the  cure  perfect. 

An  advantage  that  would  be  yielded  by  such  an  appliance  to  a 
bungling  operator  would  be  that  it  would  naturally  correct  any  im- 
perfection in  his  operation  ;  the  character  of  the  apparatus  compel- 
ling the  regular  healing  of  the  wound.  Indeed,  I  am  not  sure  but 
that  in  this  way  a  proper  mouth  might  be  made  if  the  strictly  sur- 
gical part  of  the  manipulation  consisted  only  in  a  simple  incision  to 
enlarge  the  parts  to  a  proper  capacity ;  for  in  the  operation  it  cannot 
be  said  that  the  reflection  of  the  mucous  membrane  is  an  absolute 
necessity  :  whether  this  membrane  should  be  carried  over  the  cut 
surface  or  not,  we  would  very  soon  have  it  clothed  with  such  tissue, 
or  at  least  with  that  which  would  be  found  sufficiently  analogous  to 
fairly  represent  it.  Dr.  Miitter,  in  remarking  on  the  philosophy  of 
this  operation,  suggests  that  the  annals  of  modern  surgery  hardly 
afiFord  an  example  of  greater  ingenuity  than  the  procedure  of  Dieffen- 
bach.  "  The  great  difficulty,"  he  truly  remarks,  "  in  all  these  cases 
arises  from  the  constant  tendency  to  contraction  manifested  by  the 
cicatrix,  which  occasionally  goes  on  to  such  an  extent  that  the  orifice 
of  the  mouth  is  almost  closed.  At  the  first  examination  of  such  a 
deforniit\%  the  remedy  which  seems  to  promise  most  success,"  says 
Dr.  M.,  "  is  mechanical  dilatation.  Unfortunately,  this  is  piroductive 
of  but  temporary  relief,  and  has  never,  I  believe,  effected  a  perma- 
nent cure.  Next  to  this  method  comes  incision  of  the  commissures. 
We  might  naturally  exi)ect  such  a  course  to  be  sufficient  to  effect 
the  ends  desired  ;  and  in  all  probability  this  would  be  the  case,  could 
we  by  any  means  prevent  reunion  of  the  edges  of  our  incisions. 
But  this,  it  would  appear  from  statements  of  the  best  authorities, 
has  hitherto  been  impossible;  for,  notwithstanding  the  introduction 
of  tents,  leaves  of  sheet-lead,  cerate  cloth,  etc.  between  the  li[)s  of 
the  wounds,  adhesions,  more  or  less  complete,  are  sure  to  take  place." 

The  instrument  which  I  suggest  will,  I  think,  meet  indications 
which  the  appliances  heretofore  used  have  not  been  able  to  meet. 
A  tent,  or  cerate  cloth,  or  strip  of  easily  yielding  sheet-lead  might 
not  resist  the  great  contractile  force  existing  in  these  conditions; 
something  fixed  and  immovable  is  required.  One  would  not  be 
willing  to  trust  to  a  less    resisting    body  than  the  catheter,  afier 


980  ORAL  DISEASES  AND  SURGERr. 

urethral  section.  It  might  be  asked,  "  What  need  of  such  appliances, 
if  Dieffenbach's  operation  will  effect  a  cure?"  Unfortunately,  Dieffen- 
bach's  manipulations  cannot  in  all  cases  be  carried  out.  If  the 
mucous  membrane, for  example,  participates  in  the  lesion,  the  opera- 
tion cannot  be  successfully  performed.  Or  who  can  say  tl)at  flaps 
of  mucous  membrane,  however  nicely  approximated  with  the  skin, 
will  unite  ?  There  are  several  things  whicli  may  come  between  the 
surgeon  and  success.  There  are,  at  least,  cases  which  Dieffenbach's 
nice  operation  will  not  cure. 

A  preliminary  operation,  having  the  object  of  obviating  the  tend- 
ency to  closure  of  the  n)outh,  consists  in  first  passing  through  the 
tissues,  at  the  proposed  sites  of  the  angles  of  the  lips,  setons  of  deli- 
cate india-rubber  tubing.  These  are  to  remain  in  place  until  the 
orifices  are  cicatrized,  precisely  as  in  the  case  of  the  bored  ear.  Xo 
trouble  after  this  is  experienced  in  preserving  the  mouth  as  formed. 

Studies. — Plastic  operations  about  the  lips  are  embraced  under 
the  general  name  of  cheiloplasty ;  those  upon  the  cheeks  are  termed 
genioplastic. 

The  necessity  for  such  operations  arises  from  various  causes,  not 
the  least  frequent  of  whid)  are  sections  made  by  the  knife  of  the 
surgeon.  Reference  to  Plate  X.  exhibits  five  cases ;  the  first  result- 
ing from  salivation,  the  second  from  an  ulcer,  the  third,  fourth,  and 
fifth  due  to  operations  for  the  removal  of  cancer. 

The  first  of  these  (Fig.  1)  is  described  as  having  been  a  shock- 
ing deformity.  The  operation  for  its  relief  was  performed  by  Prof. 
Miitter,  the  practice  being  as  follows.  Having  first  extracted  the  use- 
less teeth  of  the  upper  jaw,  which  would  have  prevented  the  proper 
adjustment  of  the  flaps,  or  induced  their  ulceration,  the  edges  of  the 
ulcer  were  freshened,  and  the  integuments  detached  from  the  side  of 
the  jaw.  Two  incisions,  one  above  and  one  below  the  ulcer,  as 
seen  in  the  figure,  were  made,  so  as  to  form  four  flaps.  These  were 
now  allowed  to  fall  together,  and  were  united  in  the  line  of  the  teeth 
as  far  forward  as  the  natural  angle  of  the  mouth.  The  result  was 
entirely  satisfactory. 

In  studying  this  case,  the  reader  will  remark  that  while  the  mode 
of  section,  or  making  the  flaps,  most  happily  meets  the  indications 
so  far  as  filling  up  the  seat  of  the  original  lost  tissue  is  concerned, 
yet  this  is  only  done  by  making  two  other  defects,  one  above,  the 
other  below.  Such  defects,  however,  prove,  in  healthy  tissue,  of  no 
great  consequence  ;  granulations,  quickly  springing  from  the  whole 


OPERATIONS    UPON   THE  LIPS  AND    CHEEK.     981 

circumference  of  such  wounds,  supply  the  lost  tissue  :  indeed,  in  ray 
own  experience  I  have  found,  as  a  rule,  that  the  tendency  in  these 
fresh  parts  is  to  so  rapid  a  granulation  and  cicatrization  that  fre- 
quently the  line  of  the  artificial  union  is  torn  apart. 

Fig.  1  may  be  studied  from  another  stand-point.  In  a  case 
operated  on  by  myself,  very  similar  to  the  drawing,  where  the  neigh- 
boring tissues  were  loose  and  free  in  character,  I  succeeded  in  effect- 
ing an  admirable  cure  by  simply  dissecting  the  parts  from  the  bone, 
freshening  the  edges,  and  uniting  them  by  the  ordinary  hare-lip  pin, 
supporting  the  whole  by  straps  of  adhesive  plaster  passed  from  be- 
neath the  jaw  to  the  side  of  the  head;  the  parts  at  first  looked  very 
much  stretched,  but  soon  accommodated  themselves. 

Still  another  mode  of  performing  such  operations  is  after  the 
manner  of  Taliacotius.  Freshening  the  edges  as  before,  map  out, 
by  means  of  a  piece  of  card-paper,  the  size  of  a  flap  required  to  fill 
up  the  gap ;  next  lay  this  upon  the  arm,  and,  dissecting  from  the 
integuments  its  size,  supported  by  a  pedicle,  fix  it  in  the  break  by 
means  of  stitches  of  the  interrupted  suture.  To  do  this,  the  arm 
is  to  be  brought  over  the  head,  and  thus  supported  until  union  is 
secured,  when  the  pedicle  is  to  ije  detached,  and  the  parts  trimmed 
to  suit. 

Subfig.  2,  constituting  a  second  study,  represents  an  operation 
performed  by  Mott  for  tlie  relief  of  an  anchylosis  of  the  jaw  depend- 
ent on  cicatrization  of  the  mouth  with  the  restoration  of  a  part  of 
the  cheek.  1,  exhibits  cicatrix  arising  from  an  ulcer.  This  was 
entirely  excised,  leaving  an  opening  in  the  cheek.  2,  tongue-shaped 
flap  cut  to  fill  up  the  opening  by  being  rotated  upon  its  base. 

Subfig.  3  represents  an  operation  performed  by  Prof  Pancoast  for 
the  removal  of  an  extensive  cancer,  and  the  formation  of  a  new 
lower  lip.  The  cancer  is  shown  as  circumscribed  by  a  curvilinear 
cut.  A  vertical  incision  in  the  median  line  of  the  chin  extended 
from  the  curvilinear  cut  nearly  to  the  os  hyoides,  and  another, 
which  was  horizontal  and  parallel  to  the  base  of  the  lower  jaw, 
formed  four  flaps.  The  angles  of  the  flaps  being  removed,  the  upper 
flaps  (1,  2)  were  raised  to  the  proper  level,  and  united  by  the  twisted 
suture  on  the  median  line,  when  the  lower  flaps  (3,  4)  were  also 
united  on  tlie  median  line  so  as  to  cover  the  front  of  the  chin. 

Subfig.  4  represents  a  similar  case,  treated  by  the  operation  of 
Chopart.  The  lines  show  the  idea  of  the  incisions.  2,  4,  circum- 
scribe the  disease.  1,  5,  3,  6,  show  vertical  cuts.  The  diseased 
part,  all  above  2,  4,  being  removed,  the  integuments  are  loosened 


082  ORAL  DISEASES  AND   SURGERY. 

from  the  lower  jaw,  and  simply  lifted  up,  being  retained  in  the  new 
position  by  hare-lip  pins,  or  other  convenient  form  of  suture.  This 
operation  occasionally  answers  very  well ;  in  certain  instances,  how- 
ever, where,  for  example,  it  has  been  necessary  to  stretch  the  parts, 
much  cicatricial  evulsion  is  apt  to  occur. 

Subfig.  5  represents  the  same  position  of  the  disease,  treated  after 
the  manner  of  Lallemand.  ],  the  remaining  portion  of  the  lip, 
which  is  to  be  drawn  over  to  the  angle  of  the  mouth  at  2.  A  flap, 
formed  of  the  integuments  of  the  neck,  having  been  dissected  ofi",  is 
shown  as  being  pnrtially  rotated  on  its  base,  and  about  to  be  carried 
up  to  cover  the  deficiency.  The  wound  on  the  neck  may  either  be 
approximated  at  its  edges,  or  left  to  heal  by  granulation. 

In  epithelial  cancers  quite  as  large  as  those  represented  in  Figs. 
3  and  4,  I  have  succeeded  in  securing  the  most  perfect  cures  by 
practicing  the  operation  of  Malgaigne.  This  consists  in  removing 
the  diseased  mass  by  a  simple  V-incision  ;  the  angles  of  the  mouth 
are  next  enlarged  by  horizontal  cuts,  and  the  V  drawn  together  and 
united  in  the  middle  line  of  the  face.  In  my  own  cases  I  have 
always  i)laced  a  pin  at  each  corner  of  the  mcuith  ;  as  the  result  of 
this,  some  little  puckering  is  produced,  but,  in  return,  it  eases  the 
strain  on  the  middle  line,  and  itself  disappears  after  a  very  few 
months.* 

*  The  lower  lip,  from  itsconspicuousness,  its  utility  in  articulation,  and  also 
in  tin;  prevention  of  an  involuntary  and  incessant  flow  of  saliva,  forms  a  very 
important  portion  of  the  face.  Unfortunately,  it  is  exceedingly  prone  to 
diseases  of  various  kinds,  especially  tumors  and  ulcers,  requiring  for  their 
relief  the  removal  of  the  whole,  or  a  portion,  of  the  organ  involved.  It 
would  be  worse  than  useless  to  enter  into  a  description  of  all  the  operations 
that  have  been  devised  to  remedy  its  loss,  but  a  brief  sketch  of  the  most  novel 
and  important  may  prove  useful  and  interesting  to  those  not  familuir  with 
this  department  of  plastic  surgery. 

C/iiipa}-fs  Operation. — This  operation  consists  in  making,  on  each  .side  of 
the  diseased  tissue,  a  perpendicular  incision,  extending  from  the  margin  of 
the  lip  to  a  point  below  the  base  of  the  lower  jaw  Dissecting  up  the  flap 
inclosed  between  the  incisions,  he  carefully  removed  from  its  upi)er  mar- 
gin all  the  aft'ected  tissue,  cither  by  a  iransverse  or  a  curvilinear  cut.  Then, 
pulling  upon  what  remained  of  the  flap,  he  brought  its  upper  e&*^Q  to  the  level 
of  the  margin  of  the  natural  lip,  and  there  retained  it  by  suture,  straps,  and 
placing  the  head  of  the  patient  in  such  a  manner  as  to  prevent  all  strain  upon 
the  part.  This  method,  Dr.  Mutter  remarks,  though  apparently  simj)le  and 
easj-  of  execution,  does  not  generally  answer,  in  consequence  of  the  subse- 
quent contraction  of  the  tissue. 

Horn  or  Roonhuysen's  Opei-aiion. — If  the  part  to  be  removed  bo  small,  the 


OPERATIONS    UPON   THE  LIPS  AND    CHEEK.      983 

Fig.  812  exhibits  conditions  met  with  ahiiost  every  day.     Such 
ulcerations,  being  esteemed  of  cancerous  signification,  are  commonly 


treated  by  excision.     Taking  as  example  the  two  shown  in  the  dia- 
gram, the  manner  of  removal  is  portrayed  in  the  circumscribing  lines. 


common  V-shaped  incision  is  sufficient,  and  the  parts  may  be  brought  together 
as  in  the  operation  for  hare-lip  ;  but  where  the  mass  is  large,  this  process  is 
sure  to  diminish  the  orifice  of  the  mouth,  and  thus  give  rise  to  deformity  and 
inconvenience.  To  obviate  all  this  difficulty,  it  was  proposed  by  Horn  to  de- 
tach the  adjacent  parts  by  free  dissection  from  the  maxillary  bones,  which 
would  of  course  afford  more  material  for  the  lip.  The  objection  to  this 
metbod  is,  that  in  many  cases  the  orifice  of  the  mouth  is  rendered  so  small  as 
to  be  almost  useless,  besides  presenting  great  deformity. 

Operation  of  Dupvyiren. — This,  in  ordinary 'cases,  was  nothing  more  than 
cutting  away  by  a  semi-elliptical  incision  all  the  diseased  tissue.  Granula- 
tions spring  up  from  the  margin  of  the  healthy  skin,  occupy  in  part  the  place 
of  the  original  lip,  and  conceal  to  a  certain  extent  the  deformity.  It  is  only 
in  mild  cases,  however,  that  such  a  measure  could  succeed. 

Celsian  Operation. — Having  carefully  removed  the  diseased  part  by  a  V- 
shaped  incision,  proposed  to  divide  the  tissue  remaining  horizontally,  carrying 
the  cuts  as  far  into  the  cheek  on  each  side  as  might  be  deemed  nccessarj',  after 
the  manner  of  Horn  ;  but,  in  order  to  take  off  the  strain  from  the  flaps,  he 
made  a  semilunar  incision  in  the  cheek,  just  beyond  the  base  of  each.  This 
enabled  him  to  bring  the  parts  together  without  difficulty  ;  and  the  only  ob- 
jection to  this  operation  is  the  danger  of  wounding  the  larger  vessels,  nerves, 
and  ducts  of  the  cheek,  in  making  the  semilunar  incisions. 

Operation  of  M.  Serves. — If  the  disease,  as  is  sometimes  the  case,  is  con- 
fined to  the  integuments  and  subjacent  muscles,  leaving  the  mucous  lining  of 
the  lip  sound,  Serres  cuts  away  only  the  affected  part,  and  then  turns  the 
mucous  membrane  over  the  margin  of  what  is  subsequently  to  form  the  lip. 
A  few  stitches  are  sufficient  to  hold  it  in  place,  and,  as  union  by  the  first  in- 
tention usually  occurs,  a  very  natural  and  useful  organ  may  tluis  be  made. 


984  ORAL  DISEASES  AND   SURGERY. 

The  after-treatment  consists  simply  in  approximating  the  parts  by 
the  use  of  the  pin  and  figure-of-8  ;  adhesive  strips  being  used,  or  not, 
as  mav  be  found  indicated. 


This  method,  however,  will  cmly  answer  in  cases  of  superficial  and  recent 
disease. 

Operation  of  T.  W.  Ronx. — After  removing  the  affected  tissues,  and  form- 
ing suitable  flaps  of  the  adjacent  parts,  M.  Koux  takes  away  with  the  saw  or 
cutting  instruments  the  prominent  centre  of  the  maxillary  bones,  so  as  to 
make  room  for  the  proper  and  easy  adjustment  of  the  integuments  intended 
to  replace  the  organ  destroyed.  This  operation  is  barbarous,  because  unneces- 
sarily severe. 

Operation  of  P.  Ronx — Professor  Roux,  determined  to  surpass  his  pame- 
sake,  saws  out  an  inch  or  more  of  the  bone,  and  then,  by  drawing  the  lateral 
flaps  toward  each  other,  diminishes  the  breadth  of  that  part  of  the  face  in- 
volved in  the  disease.  Then,  detaching  the  flaps,  he  draws  them  across  the 
opening  in  the  bone,  and  the  sutures  which  hold  the  soft  parts  are  generally 
suflBcient  to  hold  the  bones  in  their  proper  places. 

Operation  of  Mr.  Morgan. — This  consists  in  first  removing  the  entire  lip 
by  a  semilunar  incision,  the  concavity  of  which  is  uppermost ;  and  second,  in 
making  an  incision  also  curvilinear  and  parallel  to,  and  about  an  inch  or 
more  below,  the  first.  The  skin  included  between  the  two  is  then  carefully 
detached,  except  at  its  extremities,  and  lifted  into  the  place  occuj)ied  by  the 
diseased  lip. 

Operation  of  M.  Blasius. — M.  Blasius  has  performed  a  very  simple  ojiera- 
tion  when  the  tumor  was  large  ;  and,  according  to  his  statement,  with  decided 
success.  After  removing  the  diseased  mass  by  a  common  V-shape  incision, 
he  next  divided  the  integuments  along  the  base  of  the  lower  jaw  by  two  in- 
cisions, which  commenced  at  the  entering  angle  of  the  V,  and  extended  an 
inch  or  more  in  the  direction  specified.  Lifting  the  flaps,  he  made  them 
occupy  the  place  of  the  original  lips. 

Operation  of  Dieffenbach. — This  surgeon  has  recommended  an  operation  ap- 
parently hazardous  and  severe. 

"  Having  pared  away  the  useless  remains  of  the  former  diseased  lip,  or 
separated  the  cicatrized  margin,  a  horizontal  incision,  about  two  inches  long, 
is  carried  from  either  angle  of  the  mouth  outwards,  through  the  cheeks,  so 
as  to  throw  the  mouth  widely  open.  The  length  of  these  incisions  must  be 
regulated  according  to  the  width  of  the  mouth  ;  or,  as  a  general  rule,  the 
combined  incisions  must  somewhat  exceed  in  length  the  breadth  of  the  upper 
lip.  From  the  outer  j)oiiitof  each  of  these,  another  incision  is  next  carried 
obliquely  downwards  and  toward  the  median  line  ;  the  section  in  this  case 
likewise  extending  through  the  whole  thickness  of  the  cheek.  Thus  by  means 
of  the  first  operation  for  paring  the  cicatrix,  and  by  the  succeeding  horizontal 
and  vertical  incision,  a  flap  will  be  prepared  on  either  side  to  replace  the  de- 
fective lip;  this  flap  is  of  a  quadrangular  form,  and  maintains  a  connection 
of  more  than  one  inch  wide  with  the  soft  parts  covering  the  tissue  of  the 


OPERATIONS    UPON   THE  LIPS  AND    CHEEK.      985 

Fig.  313  exhibits  disease  involving  the  entire  lower  lip,  and  necessi- 
tating its  removal.     To  accomplish  the  necessary  end,  namely,  to 

Fig.  313.  Pig.  314. 


remove  the  disease  and  restore  the  lip,  various  means  are  employed. 
(See  foot-note.)  On  diagram  313  are  shown  the  outlines  of  an  opera- 
tion known  as  Serres's.     In  this  mode  it  is  seen  that  the  tissues  of 


lower  jaw.  It  may  be  useful  further  to  separate  the  mucous  membrane  at  its 
attaclimeiit  to  the  gums,  to  allow  of  the  more  ready  traction  of  the  flaps." 

The  severe  injury  inflicted  on  the  facial  nerve,  tlie  large  arteries  and  veins, 
and  possibly  the  parotid  duct,  has  rendered  this  operation  anything  but 
popular. 

Operation  of  Liston. — This  consists  in  first  removing  the  diseased  mass  by 
a  horizontal  and  two  perpendicular  cuts,  or  by  one  curvilinear  in  shape; 
and,  second,  in  detaching  a  flap  from  the  chin  and  neck,  twisting  it  on  its 
pedicle,  placing  it  in  the  seat  of  the  original  lip,  and  there  retaining  it  by 
suture.  After  adhesion  has  taken  place,  the  pedicle  is  divided,  and  a  wedge- 
shape  piece  removed  so  as  to  allow  the  flap  to  be  laid  down  smoothly.  This 
method,  it  is  obvious,  is  frequently  applied  to  the  restoration  of  other  parts, 
and  will  answer  here  exceedingly  well  in  many  cases.  Dr.  Mutter,  however, 
prefers  the  following  operation,  "  as  there  is  less  scar,  and  less  risk  of  slough- 
ing of  the  flaps." 

Dr.  Mutter's  Operation. — Having  first  removed  the  diseased  mass  by  a  semi- 
elliptical  incision,  two  slightly  curved  incisions  are  carried  from  the  centre 
of  this  line,  downwards  and  outwards,  to  the  base  of  the  inferior  maxillary 
bone.  Then,  from  the  terminal  extremities  of  these  incisions,  two  others  are 
carried  upwards  and  outwards  along  the  base  of  the  lower  jaw  until  they 
reach  a  point  opposite  the  initial  and  terminal  points  of  the  original  semi- 
lunar incision.  Two  quadrangular  flaps  are  thus  marked  out,  and  immedi- 
ately detached  from  the  subjacent  bones.  These  flaps  are  then  raised  and 
placed  in  the  position  originally  occupied  by  the  lower  lip,  and  then  united  to 
each  other  at  the  median  line,  and  also  by  their  lower  thirds  to  the  triangular 
piece  of  integument  (as  between  the  two  lines  which  started  from  the  centre 
of  the  semi-elliptical  incision),  by  means  of  the  twisted  suture.  By  the  ele- 
vation of  these  flaps,  a  raw  surface  is  left  on  each  side  to  heal  by  the  model- 
ing process  or  by  granulation. — Mutter. 


986  ORAL  DISEASES  AND  SURGERY. 

the  cheeks  are  utilized.  Fig.  314  shows  the  disease  removed  and 
the  wounds  dressed.  A  marked  objection  to  this  operation  is  in- 
ability to  gain  such  character  of  lower  lip  as  shall  control  the  direc- 
tion of  the  saliva,  or  permit  of  true  and  full  approximation  with  the 
superior  lip.  In  looking  at  the  new  lip,  the  reader  is  to  observe  tlie 
manner  adopted  of  covering  the  same  surface  of  the  free  border  by 
stitching  to  the  skin  the  mucous  membrane. 

Fig.  315  exhibits  a  lower  lip  removed,  and  lines  of  incision  prac- 
ticed by  Mutter  for  the  restoration  of  the  lost  part  from  the  chin. 

Fio.  315.  Fig.  31G. 


Fig.  316  shows  the  flaps  dissected  and  raised  into  place -/the  tri- 
angular spaces  being  left  to  heal  by  granulation. 

A  modification  made  by  the  author  on  the  sections  of  Miiiter — 
cuts  of  which  are  shown  in  the  clinical  reports  of  Dr.  Willard,  pub- 
lished in  the  Medical  and  Surgical  Rejjorter — consists  in  carrying 
the  vertical  lines  beneath  the  jaw,  so  that  the  flaps  when  put  in  place 
show  but  the  single  central  line  upon  the  face.  13y  this  modification 
not  only  are  observable  scars  avoided,  but  the  lip  is  not  apt  to  be 
shortened  by  the  cicatrization  :  indeed,  it  is  possible  by  such  means 
of  operating  to  oliliterate  the  triangular  breaks  left  in  the  operation 
shown,  the  yielding  integuments  of  the  neck  being  made  to  close 
the  breaks. 

The  transplantation  of  particles  of  skin,  now  an  accepted  opera- 
tion, may  be  practiced  in  the  Miitter  operation :  this  consists  in 
snipping  from  sound  parts  small  pieces  of  skin,  and  by  careful  appli- 
cation uniting  them  with  the  uncovered  surface  of  the  triangles. 

Fig.  317  exhibits  an  operation  as  practiced  by  the  author  for 
the  removal  and  restoration  of  parts  of  both  the  upper  and  lower 
lips. 

At  the  angle  of  the  mouth  is  seen  the  disease  designed  to  be 
removed,  circumscribed  by  lines  which  fully  include  it;  all  tissues 
within  these  lines  are  removed.  Commencing  now  at  the  angle  of 
the  wound  in  the  mesial  line,  an  incision  is  carried  downward  be- 


OPERATIONS    UPON  THE  LIPS  AND    CHEEK. 


987 


ueath  the  jaw,  and  outwardly — as  shown  in  the  diagram as  far  as 

the  line  of  the  facial  artery  ;  this  flap  being  next  dissected  from  its 
base  is  lifted  until  it  meets  the  free  border  of  the  natural  half  of  the 


Fro.  31/ 


lip  ;  to  this  it  is  pinned.  The  angle  seen  back  of  the  mesial  incision 
will  be  recognized  as  receiving  accommodation  in  the  second  angle 
in  the  upper  lip;  this  relationship  limits  the  size  of  the  commissure 
upon  the  side,  which  limitation,  however,  is  to  be  corrected  by  a 
subsequent  operation  practiced  after  the  manner  of  Dieffenbach. 

Remedy  for  disease  thus  situated  is  of  frequent  necessity.  The 
operation  shown  is  one  that  may  be  practiced  with  entire  satisfac- 
tion. 

Fig.  318  exhibits  lines  of  section  demanded  for  the  restoration  of  a 
lost  upper  lip.     The  case  here  shown,  being  from  life,  represents  a 


988 


ORAL  DISEASES  AND  SURGERY. 


gentleman  for  whom  only  a  few  weeks  back  the  author  found  himself 
compelled  to  remove  the  upper  lip,  within  the  inferior  lines  shown, 
for  relief  from  epithelial  ulceration.  Imagining  the  lip  away,  the 
reader  will  perceive  that  lateral  flaps  dissected  from  the  cheek,  as 


Fig.  318. 


«M#  !■ 


shown  in  the  diagram,  must  admit  necessarily  of  being  brought 
down  and  stitched  together  in  the  place  of  the  lost  part. 

Fig.  319,  demonstrative  of  the  same  operation,  exhibits  the  face 
of  a  patient  when  first  presenting  for  treatment. 

Fig.  320  exhibits  the  appearance  of  the  face  immediately  after 
the  completion  of  an  operation  for  a  new  lip,  practiced  precisely  as 
shown  by  the  lines  marked  upon  the  face  of  Fig.  318.  The  tri- 
angular space,  left  necessarily  on  each  cheek,  as  must  be  appre- 
ciated by  a  study  of  the  drawing,  on  the  left  side  is  shown  obliterated 
by  compelling  the  cheek  to  override  the  space.  On  the  right 
side  the  space  has  been  allowed  to  remain.  The  artist,  however, 
should  have  represented  the  ulcer  by  a  dark  rather  than  by  a  light 
surface. 


OPERATIONS    UPON  THE  LIPS  AND    CHEEK.      989 

The  lady  represented  in   Fig.  321   applied  to  the  author  three 
years  back  for  relief  from  the  deformity  exhibited,  the  irregularity 
Fio.  319.  Fig.  320. 


of  features  being  dependent  upon  injury  done  the  facial  nerve  in  an 
inflammation  and  necrosis  of  the  temporal  bone  from  accident  met 

Fig.  321. 


with  in  childhood.  Paralysis  was  complete;  not  the  slightest  power 
existed  in  the  muscles  of  the  affected  side. 


990 


ORAL   DISEASES  AND   SURGERY. 


The  desire  of  the  patient  was  for  a  symmetrical  mouth  and  face  ; 
the  question  was,  the  accomplishment  of  such  an  end. 

Treatment. — A  case  of  this  kind  treated  bj  any  of  the  various 
means  of  nerve-stimulation  is,  of  course,  a  consideration  not  involved. 
What  is  done  can  only  be  from  the  mechanical  stand-point.  The 
indications  were  threefold  : 

1st.  To  reduce  the  flabby  redundancy  of  the  paral3^zed  cheek. 

2d.  To  give  comeliness  and  regularity  to  the  month. 

3d.  To  antagonize  the  muscular  action  (when  in  play)  of  the 
vital  side. 

In  this  case  these  indications  were  attempted  to  be  met  by  means 
as  follows :  A  study  was  made  of  the  cheek,  and  what  was  deemed 

Fio    ?,22. 


to  be  the  redundant  tissue  was  included  in  an  ellipse  drawn  with  a 
lead-pencil,  one  of  the  apices  being  at  the  middle  of  the  nose,  the 
other  at  the  angle  of  the  lower  jaw, — such  direction  of  the  ellipse 
being  with  a  purpose  of  raising  the  angle  of  the  mouth.  Satisfied 
that  such  removal  would  be  found  rightly  placed  to  meet  the  two 
first  indications,  the  part  was  cut  out.  In  the  operation  the  facial 
artery  was  the  only  vessel  which  needed  a  ligature,  and  even  this 
ejected  no  more  blood  than  does  an  ordinary  coronary. 

To  bring  the  parts  together,  three  hare-lip  pins  were  used,  and 


OPERATIONS    UPON   THE  LIPS  AND    CHEEK.      991 

agreeably  to  my  surprise,  so  direct  and  immediate  was  the  union 
that  it  was  found  permissible  to  dispense  with  two  of  them  on  the 
following  day  ;  the  third,  the  middle  one,  was  left  in  until  the  fourth 
day;  but  this,  not  seemingly  from  any  necessity.  The  ligature,  a 
strand  of  ordinary  silk,  remained  firm  for  three  weeks,  and  was 
finally  taken  away  only  by  the  use  of  a  traction  quite  as  great,  I 
should  think,  as  would  have  sufficed  for  its  removal  the  moment 
after  it  was  placed  about  the  vessel. 

The  result  of  this  procedure  is  exhibited  in  Fig.  322.  With  the 
features  in  a  state  of  rest,  nothing  more,  it  would  seem,  could  be 
desired. 

The  third  indication,  however,  showed  itself  a  most  important  one. 
Emotion  of  the  face  altered  this  mechanical  harmony  of  the  parts, 
and  exhibited  the  non-vitality  of  the  side  operated  upon  ;  that  is 
to  say,  in  laughter,  for  example,  the  superior  and  lateral  levators 
would  pull  up  the  well  angle,  with  no  corresponding  action  on  the 
diseased  side.  This  was,  of  course,  a  matter  which  had  been  origi- 
nally considered.  The  indication  was  met  with  remarkable  success, 
as  follows  :  A  piece  of  rubber  tubing  four  inches  long,  possessed  of 
an  elastic  power  adapted  to  the  requirements  of  the  case,  was  at- 
tached by  one  of  its  ends  to  a  hair-pin  (the  ordinary  pin  used  by 
ladies  iu  dressing  the  hair).  To  its  other  end  was  united  a  p'ece  of 
strong,  but  delicate,  gill-net  string,  and  this,  in  turn,  was  connected 
with  a  small  strip  of  flesh-colored  court-plaster. 

The  application  of  this  piece  of  mechanism — an  artificial  muscle, 
let  us  call  it — was  made  as  follows  :  The  plaster  was  softened  and 
applied  to  the  dead  side  of  the  face,  as  far  back  upon  the  cheek  as 
would  answer  the  purpose.  "When  fixed,  the  lady,  standing  before 
her  glass,  would  excite  the  displacing  muscles  into  play,  and  antago- 
nize them  by  drawing  slightly  backward  the  dead  side  with  the 
artificial  muscle,  and  fix  it  in  such  required  tension  by  the  pin  fixed 
into  one  of  the  coils  of  her  hair,  the  rubber  lying  entirely  concealed 
by  such  coil.  When  applied,  only  the  plaster  could  be  seen,  the 
string  being  hidden  by  the  hair. 

This  rubber  muscle  answered  its  purpose  admirably.  The  fear 
that  the  plaster  would  irritate,  and  perhaps  ulcerate,  the  skin,  seems 
to  have  been  without  foundation.  At  any  rate,  this  held  good  for 
six  months  of  use,  which  was  as  long  as  I  was  able  to  have  over- 
sight of  the  case,  the  lady  living  in  a  distant  city.  Should,  however, 
this  accident  have  supervened,  it  was  evident  that,  after  a  very  few 
days  of  experience,  a  habit  might  soon  be  attained  of  accomplishing 


992 


ORAL  DISEASES  AND  SURGERY. 


Fig.  323. 


tbe  same  object  by  the  use  of  the  fingers  applied  in  such  manner  as 
not  to  elicit  attention. 

This  operation,  the  only  one  of  the  kind  I  have  performed,  has 
given  results  which  I  think  will  warrant  its  repetition. 

Fig.  323  exhibits  an  operation  practiced  by  the  author  for  the 
relief  of  an  epithelial  ulceration  involving  the  full  lower  eyelid  and 

a  limited  portion  of  the  upper.  The 
study  of  this  operation  illustrates  a  class 
in  this  direction.  First,  as  seen  in  the 
diagram,  the  diseased  structure  is  fully 
removed  through  incision  associated 
with  the  uninvolved  surrounding  parts. 
Second,  the  hemorrhage  being  entirely 
controlled,  a  flap  to  replace  the  lost  part 
was  made,  as  shown  in  the  inferior 
lines  ;  this  flap  being  raised  was  carried 
upward,  the  convex  portion  being  as- 
sociated with  the  concave  break  re- 
sulting from  the  section  of  the  upper 
lid, — the  slightly  concave  portion  repre- 
senting the  superior  line  of  the  lower 
lid.  The  triangular  portion,  seen  in 
the  diagram  to  exist  at  tbe  side  of  the 
ala  between  the  two  incisions,  was 
next  dissected  from  its  apex  toward 
its  base,  and  being  dissected  below  what,  in  the  diagram,  is  seen  to 
be  the  inferior  flap,  was  thus  brought  into  relation  with  healthier 
influences,  while  a  similar  good  was  secured  for  the  new  eyelid  in 
making  it  of  tissue  which  had  not  been  in  immediate  juxtaposition 
with  the  diseased  part  removed. 

In  this  particular  operation  no  trouble  was  found  in  completely 

filling  the  gap  made  by  the  dissection,  the  loose  tissue  of  the  neck 

and  side  of  the  face  being  found  amply  sufficient  to  meet  the  demands. 

In  studying  the  incisions  here  practiced,  tbe  practitioner  will  find 

all  required  hints  for  the  various  transpositions  demanded. 


Burns. — Plastic  operations  practiced  for  the  relief  of  cicatricial 
deformities  must  always  be  of  special  signification.  Of  such  cica- 
trices there  are  of  course  an  endless  variety,  and  it  may  only  be 
that  each  case  shall  command  a  special  operation. 

Cicatricial  tissue,  always  the  result  of  suppurative  inflammatory 


OPERATIONS    UPON   THE  LIPS  AND    CHEEK.      998 

action,  is  a  species  of  imperfect  fibrous  formation,  dull  white  in  color, 
hard,  its  fibres  running  in  every  direction  and  possessed  of  a  con- 
tractility which,  in  many  instances,  requires  years  for  its  exhaustion. 
In  vital  force  this  structure  is  of  low  organization,  peculiar! v  sus- 
ceptible to  degenerating  influences,  rarely,  if  ever,  developing  to  full 
likeness  with  its  associated  parts. 

The  surgeon  in  treating  a  cicatrix  will  find  himself  wisely  influ- 
enced in  heeding  the  maxims  of  Dupuytren: 

"  1.  Never  attempt  the  correction  of  a  deformity  until  months,  and 
in  many  instances  years,  have  passed  after  its  production. 

"  2.  Never  operate  unless  certain  of  obtaining  a  larger  cicatrix  than 
that  which  is  wished  to  be  removed. 

"  3.  Be  certain  that  the  operation  can  restore  the  parts  to  their 
shape." 

Dermoplasty,  as  this  operation  is  called,  is  never  to  be  undertaken 
without  full  consideration  of  the  shock  to  be  entailed  by  the  cutting 
and  suppuration,  and  the  ability  of  the  patient  to  endure  such  shock 
(see  page  601).  In  removing  a  cicatrix,  let  Fig.  323  exhibit  an 
example;  it  is  to  be  recognized  that  not  only  may  a  prolonged  dis- 
section be  necessitated,  but  the  cutting  is  not  at  all  unlikely  to  be  of 
the  m,ost  hazardous  nature,  requiring  on  the  part  of  the  surgeon 
not  only  a  most  accurate  knowledge  of  the  anatomy  of  the  parts  in- 
volved, but  also  a  patience  and  a  manipulative  skill  which  are  by  no 
means  a  common  possession. 

A  secondary  danger  associated  with  these  operations  lies  in  the 
superv^ention  of  erysipelas,  a  contingency  to  be  guarded  against  by 
that  preliminary  attention  which  has  taken  into  consideration  every 
functional  irregularity  which  can  have  a  tendency  to  lower  the 
resistive  force  of  the  individual  locally  or  at  large.* 

A  flap  is  always  to  be  at  least  from  a  quarter  to  a  third  larger  than 
the  cicatrix  to  be  replaced  ;  such  increased  size  will  be  found  necessary 
to  counterbalance  the  shrinkage.  ,^ 

A  flap  is  always  to  be  taken  from  the  nearest  healthy  neighboring 
part.  It  is  to  have  the  widest  pedicle  the  circumstances  of  the  case 
will  permit,  and  is  not  to  be  laid  in  its  new  situation  until  all 
hemorrhage  has  been  fully  suppressed  and  both  flap  and  base  are 
found  covered  with  a  film  of  plasm. 

In  fixing  a  flap,  unnecessary  stitches  are  to  be  avoided,  while  com- 


*  Ery.sipelas  would  seem  to  be  a  parasitic  disease ;  the  fungi  finding  habitat 
in  a  part  incapable  of  self-defense  or  resistance. 

62 


994  ORAL  DISEASES  AND   SURGERY. 

pression  of  the  most  gentle  nature  is  to  be  used  in  holcling  the  parts 
in  apposition. 

■  No  dressing  except  of  the  simplest  character  is  to  be  used  after 
an  operation ;  the  surgeon  is  to  take  it  for  granted  that  no  complica- 
tion will  arise  and  that  the  union  is  to  be  immediate  and  full :  sl)0uld, 
however,  such  results  not  accrue,  then  indications  are  to  be  met  as 
they  may  arise. 

Concerning  the  wound  left  l)y  the  transfer  of  the  flap,  it  is  best 
treated  by  the  endeavor  to  close  it  by  the  overdrawing  of  neighl)or- 
ing  parts  ;  in  large  wounds,  however,  where  this  practice  may  not 
avail,  the  process  of  skin-grafting  is  to  be  had  recourse  to;  this, 
while  not  so  reliable  as  is  to  be  desired,  serves  at  times  a  most 
satisfactory  end. 

As  studies  iu  this  direction  of  surgery,  see  foot-note.* 

*  "  Miss  Mary  S.,  aged  twenty,  daughter  of  the  Hon.  William  S.,  of  Ohio, 
came  to  Wheeling,  in  the  spring  of  1848,  to  obtain  relief  from  the  effects  of  a 
very  .severe  burn,  which  she  had  received  fifteen  years  before.  The  burn 
was  princiyially  confined  to  the  necli  and  lower  part  of  the  face,  and  its  cica- 
tri.v  produced  a  deformity  of  the  most  dreadful  character.  Her  head  was 
drawn  downward  and  forward,  the  chin  was  confined  within  an  inch  of  the 
sternum,  the  under  lip  was  so  pulled  down  that  the  mucous  membrane  of  the 
left  side  came  far  below  the  chin,  the  under  jaw  was  bowed  slightly  down- 
ward, and  elongated,  particularly  its  upper  portion,  which  made  it  project 
about  one  inch  and  three-eighths  beyond  the  upper  jaw.  In  front  there  was 
scarcely  any  appearance  of  either  chin  or  neci\.  She  was  unable  to  turn  her 
head  to  either  side  ;  the  cheeks  and  upper  lip  were  dragged  considerably 
downward  ;  she  could  not  close  her  eyelids ;  she  could  not  close  her  jaws  but 
for  an  instant,  and  then  only  by  .bowing  her  head  forward.  She  could  not 
retain  her  saliva  for  a  single  instant ;  and,  as  might  be  expected,  her  articula- 
tion was  very  indistinct. 

'■She  had  been  taken  to  the  city  of  Xew  Tork,  some  years  before,  for  the 
purpose  of  being  relieved  from  this  deformity,  and  was  placed  under  the  care 
of  two  of  the  most  distinguished  surgeons  in  that  city,  who  performed  an 
operation  by  dissecting  up  the  cicatrix  on  the  neck,  then  raising  the  head 
and  sliding  up  the  cicatrix  from  its  original  position,  leaving  a  raw  surface 
below  to  heal  up  by  granulation.  I  need  scarcely  add  that  the  operation  was 
entirely  unsuccessful. 

"After  a  careful  observation  of  the  case,  it  became  evident  that  such  a 
complicated  deformity  could  be  best  remedied  b}'  performing  three  se])arate 
operations, — one  upon  the  jaw,  another  upon  the  neck,  and  a  third  upon  the 
under  lip. 

"To  remove  the  projection  of  the  under  jaw  seemed  to  require  the  first 
attention.  Unless  that  could  be  done,  the  other  operations,  however  suc- 
cessful, would  add  but  little,  if  any,  to  the  personal  appearance  of  the  patient. 


OPERATIONS   UPON  THE  LIPS  AND    CHEEK.      995 

This  lengthening  of  the  jaw  had  taken  place  entirely  between  the  cuspidatus 
and  first  bicuspid  tooth  of  the  right  side,  and  between  the  first  and  second 
bicuspids  of  the  left.  By  the  elongation,  the  teeth  just  described  were  sepa- 
rated on  both  sides  about  three-fourths  of  an  inch. 

"  To  saw  out  the  upper  edge  of  these  elongated  portions  of  the  jaw,  and 
then  to  divide  that  part  of  the  jaw  in  front  of  the  spaces  thus  made,  by  sawing 
it  through  in  a  horizontal  manner,  so  as  to  permit  the  upper  and  detached 
portion  to  be  set  back  in  its  original  position,  appeared  to  be  the  only  possible 
way  of  remedying  the  deformity.  This  plan  I  therefore  adopted,  and  per- 
formed the  operation  on  the  12th  day  of  June,  in  the  manner  now  to  be 
described. 

"  The  operation  was  commenced  by  sawing  out,  in  a  V-shape,  the  elongated 
portions,  together  with  the  first  bicuspid  on  the  left  side,  each  section  extend- 
ing about  three-fourths  of  the  way  through  the  jaw.  I  then  introduced  a 
bistoury  at  the  lower  point  of  the  space  from  which  the  section  was  removed 
on  the  right  side,  and  pushed  it  through  the  soft  parts  close  to  and  in  front  of 
the  jaw,  until  it  came  out  at  the  lower  point  of  the  space  on  the  left  side. 
The  bistoury  was  then  withdrawn,  and  a  slender  saw  introduced  in  the  same 
place,  and  the  upper  three-fourths  of  the  jaw,  containing  the  six  front  teeth, 
was  sawed  off  on  a  horizontal  line,  ending  at  the  bottom  of  the  spaces  before 
named,  the  detached  portion  being  still  connected,  on  the  outer  and  inner 
sides,  to  the  jaw  below,  by  the  soft  parts. 

"  After  having  with  the  bone  nippers  removed  from  the  detached  portion 
the  corners  wliich  were  created  by  the  horizontal  and  perpendicular  cuts  of 
the  saw,  it  was  set  back,  so  that  the  edges  from  which  the  V-shaped  sections 
were  removed  came  together. 

"  Thus  it  will  be  perceived  that  this  portion  of  jaw  and  teeth,  which  before 
projected  and  inclined  outward,  now  stood  back  and  inclined  inward,  and  in 
its  proper  and  original  place. 

"  In  this  position  the  jaw  was  secured  by  passing  ligatures  around  the  cus- 
pidati  in  the  detached  portion  and  the  now  adjoining  bicuspids  in  the  sound 
portion  ;  then,  taking  an  impression  of  the  jaw  in  very  soft  wax,  a  cast  was 
procured,  and  a  silver  plate  struck  up  and  fitted  over  the  teeth  and  gum,  in 
such  a  manner  as  to  maintain  the  parts  in  that  same  relation,  beyond  the 
possibility  of  movement. 

"  The  patient  declared  that  the  operation  gave  her  little  or  no  pain.  There 
was  a  little  swelling  about  the  chin  during  the  first  three  days  after  the  opera- 
tion, but  not  the  slightest  uneasiness.  In  this  way  the  case  progressed ;  the 
gum  healed  in  a  few  days,  the  jaws  united  strongly,  and  in  the  time  bones 
usually  unite,  and  the  wearing  of  the  plate  was  discontinued  within  six 
weeks  after  the  operation  was  performed. 

"  Tlie  deformity  of  the  jaw  being  now  removed,  the  next  thing  to  be  done 
was  to  relieve  the  confined  condition  of  the  head,  and  the  distortion  of  the 
face  and  neck  resulting  therefrom.  This  I  determined  to  accompli-sh,  if 
possible,  after  the  manner  of  Prof.  jVIiitter  in  similar  cases,  and  I  accordingly 
performed  the  operation  on  the  31st  day  of  July,  assisted  by  Dr.  Wissell. 

"  I  began  by  dividing  the  skin  immediately  in  front  of  the  neck,  about 


996  ORAL  DISEASES  AND  SURGERY. 

half  an  inch  above  the  sternum,  and  then  carried  the  incision  hack  about 
three  inches  on  each  side.  I  then  commenced  a  careful  division  of  the 
strictures,  which  were  so  thickened  in  front  as  to  extend  to  the  trachea,  and 
on  the  sides  as  not  only  to  involve  the  platysma  myoides,  but  a  portion  of 
the  sterno-cleido-mastoid  muscle  also.  After  dividing  everything  that  inter- 
fered with  the  raising  of  the  head  and  the  closing  of  the  mouth,  as  far  as  the 
incision  was  now  made,  it  became  evident  that,  to  give  free  motion  to  the 
head,  the  incision  on  the  neck  must  be  extended  back  through  the  remaining 
cicatrix,  which  was  at  least  two  inches  wide  on  one  side,  and  about  an  inch 
and  a  half  on  the  other. 

"This  was  accordingly  done,  the  whole  presenting  a  wound  upwards  of 
nine  inches  in  lengtli  and  nearly  five  in  width.  A  thin  piece  of  leather  was 
now  cut  in  shape  of  the  wound,  but  somewhat  larger,  and  placing  it  upon  the 
shoulder  and  arm,  immediately  over  the  deltoid  muscle,  a  flap  nearly  ten 
inches  in  length  and  live  in  breadth,  having  an  attachment  or  neck  two  inches 
wide,  was  marked  out,  and  then  dissected  up  as  thick  as  the  parts  below 
would  permit.  This  flap  was  now  brought  around  and  secured  in  the  Avound 
on  the  neck  by  the  twisted  suture,  the  sutures  being  placed  about  an  inch  and 
a  half  apart.  Between  each  of  these  sutures,  one,  two,  and  sometimes  three 
small  stitches  were  inserted,  depending  entirely  upon  the  number  necessary 
to  bring  the  edges  neatly  together.  These  stitches  were  of  fine  thread,  had 
a  very  superficial  hold,  produced  little  or  no  irritation,  and  served  to  keep 
the  parts  in  better  apposition  than  any  other  mean.s  I  could  have  devised. 
The  wound  of  the  shoulder  was  next  drawn  together  about  one-half  of  its 
entire  extent ;  the  remainder  was  covered  with  lint.  One  long,  narrow  strip 
of  adhesive  plaster  applied  around  the  neck  to  support  the  flap,  and  over  this 
a  cravat  tied  in  the  usual  way,  constituted  all  the  dressing  deemed  advisable 
at  this  time. 

"  The  patient  bore  this  tedious  and  very  painful  operation  with  great  forti- 
tude, and  uttered  scarcely  a  murmur.  She  was  somewhat  exhausted,  but  not 
from  the  loss  of  blood.  There  was  no  vessel  divided  of  suflScicnt  importance 
to  require  a  ligature. 

"  August  1st.  Daring  the  fore  part  of  last  night  the  patient  was  somewhat 
distressed,  was  very  unmanageable,  would  talk  incessantly,  and  occasionally 
sat  up  in  bed.  An  anodyne  was  administered  at  twelve  o'clock,  after  which 
she  rested  much  better  and  slept  some.  Complains  of  sickness  of  the  stomach 
this  morning;  has  vomited  three  or  four  times  ;  flap  very  pale  ;  pulse  rather 
weak.     Directed  to  refrain  from  all  kinds  of  drinks. 

"2d.  Complains  only  of  pain  in  the  shoulder;  was  much  distressed  the 
latter  part  of  last  night,  on  account  of  a  retention  of  urine.  The  catheter 
was  employed,  and  about  three  pints  of  urine  drawn  ofl",  after  which  she 
rested  well.     Pulse  somewhat  excited  ;  flap  better  color. 

"  3d.  The  patient  rested  well  last  night;  the  use  of  the  catheter  still  neces- 
sary. All  efi'orts  to  keep  the  patient  from  talking  and  moving  unavailing; 
color  of  the  flap  rather  pale,  save  at  the  extreme  point  and  about  two  inches 
along  the  lower  edge,  which  is  assuming  rather  a  dark-blue  color.  Pulse 
about  the  same  as  yesterday  ;  removed  a  pin  from  near  the  point  of  the  flap, 


OPERATIONS    UPON   THE  LIPS  AND    CHEEK.      997 

and  enveloped  the  neck  in  cotton  batting.     Patient  complains  of  hunger; 
chicken  broth  ordered. 

"  4th.  Patient  rested  well ;  the  use  of  the  catheter  yet  necessary  ;  complains 
of  slight  headache;  the  color  of  the  flap  nearly  natural,  and  even  the  point 
is  assuming  a  healthy  hue,  and  appears  to  be  uniting ;  pulse  almost  natural. 

"5th.  Urinates  without  difficulty;  bowels  moved  by  injections;  patient 
entirely  free  from  pain  ;  pulse  natural. 

"6th.  Dressing  removed;  the  flap  is  uniting  by  the  first  intention  along 
both  sides,  throughout  its  entire  extent;  the  greater  part  of  the  pins  and 
stitches  removed. 

"7th.  The  remainder  of  the  pins  and  stitches  removed;  patient  perfecth' 
comfortable  and  cheerful. 

"  10th.  Sat  up  all  day  by  the  window. 

"16th.  Walked  out  to  take  an  airing. 

"  During  the  whole  progress  of  the  cure  there  was  not  the  slightest  swelling 
or  undue  inflammation  in  the  flap  or  about  the  neck.  The  patient  was  slightly 
hysterical  for  the  first  few  days,  but  never  complained  of  anything  but  pain 
in  the  shoulder,  a  slight  headache  of  a  few  hours'  duration,  and  the  uneasiness 
occasioned  hj  the  retention  of  urine.  The  wound  on  the  shoulder  granulated 
rapidly  and  skinned  over  in  about  six  weeks  after  the  operation.  It  was 
curious  to  observe  that  upon  touching  the  flap  after  it  had  healed  in  the  neck 
the  patient  would  always  refer  the  sensation  to  the  shoulder  or  arm  from 
which  the  flap  was  taken. 

"  The  confinement  of  the  head  and  the  distortion  of  the  face  occasioned  by 
the  strictures  being  now  removed,  the  next  step  was  to  relieve,  as  fiir  as  pos- 
sible, the  very  great  deformity  of  the  under  lip. 

"The  under  lip,  from  being  dragged  down  and  greatly  stretched  by  the 
former  projection  of  the  under.jaw,  was  rendered  greatly  too  large,  so  that  it 
pouted  out  an  inch  or  more  farther  than  the  upper  lip.  This,  together  with 
a  turning  out  of  the  mucous  membrane  on  the  left  side,  which  extended 
nearly  down  to  the  lower  edge  of  the  chin,  making  the  lip  too  short  on  that 
side,  was  the  nature  of  the  deformity  yet  to  be  relieved. 

"To  remove  this  unseemly  appearance  of  the  lip,  the  inverted  portion  was 
cut  out  in  a  V-shape,  extending  down  to  the  flap  in  the  neck,  and  sufficiently 
large  to  reduce  the  lip  to  its  proper  size.  The  edges  were  then  brought 
together,  and  secured  after  the  manner  of  a  single  hare-lip.  The  wound 
healed  in  the  most  beautiful  manner,  and  the  appearance  of  the  lip  was 
greatly  improved  ;  but  there  yet  remained  a  deep  depression  or  notch  in  tho 
edge,  sufficiently  large  to  keep  exposed  the  tops  of  two  or  three  teeth,  besides 
preventing  the  coming  together  of  the  lips  on  that  side. 

'•'  I  now  determined  to  raise,  if  possible,  this  depressed  portion  of  the  lip, 
and  for  this  purpose  I  passed  a  bistoury  through  the  lip,  about  two  lines  from 
the  free  edge,  first  on  one  side  of  the  depression  and  then  on  the  other,  and 
then  carried  the  incisions  downward  to  meet  at  a  point  on  the  lower  edge  of 
the  chin. 

"  The  depressed  portion  of  lip  now  lying  between  the  two  incisions  was 
next  dissected  loose  from  the  jaw,  and  then  raised  to  a  level  with  the  re- 


998 


ORAL  DISEASES  AND   SURGERY. 


mainder  of  the  lip,  and  there  retained  by  pins,  after  the  manner  of  dressing 
a  double  hare-lip,  the  line  of  union  forming  a  letter  V. 

"  This  operation  was  as  successful  as  the  others,  and,  the  original  deformity 
being  now  removed,  the  young  lady,  though  still  bearing  evidences  of  the 
burn,  has  the  free  use  of  her  head,  eyelids,  jaws,  and  lips,  and  may  mingle 
in  society  without  particular  note  or  remark." 


CHAPTER    XLYIII. 

RHINOPLASTIC   AND    RHINO-CHEILOPLASTIC    OPERATIONS. 

Defects  of  the  nose,  requiring  relief  through  plastic  operations, 
vary  markedly  in  character:  thus,  the  parts  may  be  complete]}"  lost, 
or  only  one  ala  may  be  absent ;  a  break  in  the  continuity  of  the 
side  may  exist,  as  shown  in  Fig,  330  ;  or  with  the  loss  of  one  side 
may  be  conjoined  a  misshaped  and  sunken  condition  of  the  opposite, 
as  seen  in  Fig.  326  ;  nose  and  lip  may  both  be  wanting,  as  exhibited 
in  Fig.  319;  or,  as  is  often  seen,  Y-shaped  breaks  may  exist  in  the 
continuit}"  of  the  free  surface  of  one  or  the  other  of  the  al«. 

Four  general  features  associate  with  the  operations  of  rhino- 
plasty, namely :  the  Italian,  the  German,  the  Indian,  and  the 
English  method. 

The  Italian  method  is  that  known  as  the  operation  of  Tagliacozzi. 
This  is  practiced  by  marking  upon  the  inner  and  middle  portion  of 
the  integuments  of  the  arm  two  longitudinal  lines  four  inches  at 
least  in  length  by  three  and  a  half  in  i)readth  ;  the  flap  thus  out- 
lined is  now  raised,  and,  while  allowed  to  remain  attached  at  either 
end,  is  separated  its  length  from  the  underlying  parts  by  well-oiled 
linen  or  sheet-lead  passed  beneath  it.  Allowed  thus  to  remain  until 
it  becomes  thickened  and  indurated,  a  period  of  some  two  weeks, 
the  one  end  is  detached,  and  the  oblong  flap,  being  pared  into  shape, 
is  now  stitched  to  the  face,  which  has  been  prepared  for  its  reception. 

The  German  method,  being  a  modification  of  the  preceding  made  by 
Prof.  Yon  Graefe,  of  Berlin,  consists  in  the  performance  of  the  whole 
operation  at  a  single  sitting.  This  method,  while  advantageous  as 
regards  the  comfort  of  the  patient,  yet  fails  to  secure  tliat  thick- 
ness of  substance  in  the  flap  which  was  the  object  with  Tagliacozzi 
in  subjecting  it  to  such  long-continued  irritation;  also  the  shrinkage 
has  to  occur  in  the  part,  as  a  nose,  rather  than  as  a  flap. 

The  Indian  method,  the  one  most  generally  practiced,  consists  in 
taking  the  flap  for  the  bridge  and  alas  from  the  forehead,  and  the 
columna  from  the  lip. 

The  English  method,  devised  and  first  practiced  by  Prof  Syme, 
of  Edinburgh,  consists  in  taking  flaps  from  the  cheek,  as  is  shown 

(999) 


1000 


ORAL  DISEASES  AND  SURGERY 


Fio.  32  k 


for  one  ala,  in  Fig.  326.     In  this  operation  the  columna  is  also  to 
be  obtained  from  the  lip. 

Fig  5,  Plate  XIII.,  exhibits  the  flap,  as  made  after  the  manner  of 
Tagliacozzi ;  also  the  manner  of  attachment  to  the  face,  together  with 
the  means  practiced  by  that  surgeon  to  fix  the  forearm  over  the  head. 
Fig.  4  shows  the  Indian  operation  ;  the  general  Y-shape  of  the 
flap,  conjoined  with  the  strip  for  the  columna,  is  recognized  in  the 
ulcer  on  the  forehead  ;  the  flap,  rotated  on  its  pedicle,  is  seen  to  be 
raised  in  its  new  position  into  the  shape  of  the  nose  by  bougies 
introduced  into  the  nostril-spaces. 

Studies. — Fig.  324  exhibits  a  case  in  which  the  al«?  and  cartilagi- 
nous septum  of  the  nose  have  been  lost.  In  this  case  th^  defect  is  pro- 
posed to  be  remedied  by  material 
to  be  taken  from  the  forehead,  after 
the  Indian  method.  First,  the  size 
and  shape  of  the  new  wings  are 
mapped  out  with  ink,  as  shown. 
To  so  map  out  the  organ  it  becomes 
necessary,  first,  to  have  a  complete 
idea  of  what  is  needed;  this  is 
obtained  by  using  a  thin  sheet  of 
gutta-percha,  which,  on  being 
warmed,  may  be  moulded  as  de- 
sired. Obtaining  thus  the  size, 
the  material  is  spread  out  upon 
the  forehead,  as  shown  in  the  cut. 
It  now  remains  to  freshen  the  cir- 
cumference of  the  parts  to  be  re- 
stored, and,  dissecting  the  flap  from  the  forehead,  plenty  being  allowed 
for  shrinkage,  twist  it  upon  the  pedicle,  which  of  course  is  allowed  to 
remain,  and  by  means  of  ligatures  fix  the  flap  in  the  new  position.* 
The  separation  of  the  pedicle  is  only  to  be  practiced  after  full  re- 
lationship of  circulation  is  established  in  the  newly-related  parts, — 
a  period  varying  from  ten  days  to  as  many  weeks. 

The  convex  position  of  the  new  nose  and  the  maintenance  of  the 
orifice  are  to  be  secured  by  tubes  of  silver,  worn  for  several  months. 
Fig.  325  shows  a  frequent  result  of  such  a  rhinoplastic  operation. 


*  A  manner  of  relating  the  parts,  devi.-ied  hj'  Prof.  Pancoast,  is  known  as 
the  tongue  and-groove  suture:  this  consists  in  associating  two  surfaces  by 
means  of  convex  and  concave  faces. 


BHINO-  AND  EHINO-CHEILOPLASTIC  OPERATIONS.   1001 


Fig.  326,  being  a  case  from  the  practice  of  Prof  D.  Hayes  Agnew, 
in  wbich  the  author  had  the  pleasure  to  assist,  exhibits  the  loss  of  fully 
oue-half  the  nose.  lu  this  instance  it  is  perceived  that,  besides  the 
loss  of  the  aria,  the  remaining  nostril,  as  the  result  of  a  cicatricial 
depression  at  the  bridge,  has  been  made  to  look  unduly  outward, 


Fig.  Z-2C,. 


Fig.  :327. 


the  organ  being  converted  into  a  very  decided  pug.  Two  indica- 
tions are  here  seen  to  exist :  first,  the  body  of  the  nose  is  to  be  let 
down  ;  secondly,  a  new  ala  is  to  be  made.  Turning  now  to  the  lines 
of  incisions,  it  is  perceived  how  these  indications  were  attempted  to 
be  met.  First,  across  the  bridge  is  seen 
the  first  cut  made ;  this  incision,  with  a  little 
dissecting,  allowed  tlie  part  to  drop  as  re- 
quired; secondly,  commencing  upon  the 
nasal  prominence,  as  seen  in  the  diagram, 
an  incision  was  brought  down,  and,  after 
extending  a  very  short  distance,  was  made 
to  assume  a  triangular  form,  thus  affording 
a  pyramidal  slip  to  occui)y  the  triangular 
space  necessarily  resulting  from  the  drop- 
ping of  the  nose;  thirdly,  continuing  the 
line  of  incision,  the  cut  was  carried  into 
the  substance  of  the  cheek,  as  shown  in  the 

drawing,  the  form  of  flap  created  being  in  accordance  with  the  wants 
of  the  part  to  be  restored  ;  fourthly,  the  edge  of  the  nose  was  fresh- 
ened, and  the  triangular  flap  seen  below  was  dissected  to  its  base. 


1002 


ORAL  DISEASES  AND   SURGERY. 


All  being  thus  ready,  the  alfe  flap  was  brought  into  place  and 
attached,  while  the  inferior  flap  was  forced  outward  to  help  fill  up 
the  space  left  vacant  by  the  removal  by  the  triangular  apex  of  the 
alas  flap. 

Fig.  321  exhibits  an  operation  similar  to  that  shown  in  Fig.  324, 
the  new  nose  being  here  seen  stitched  in  place,  and  the  wound  on 
the  forehead  approximated. 

Fig.  328  exhibits  a  facial  loss  of  substance,  together  with  the  pro- 
posed mode  of  correction. 

Fig.  329  exhibits  the  flap,  as  made  in  Fig.  328,  in  place,  with  the 
wound  of  the  forehead  approximated,  the  various  pins  and  stitches 
required  being  shown. 


Fia.  328. 


Fig.  329. 


Plate  XIY.  is  one  of  the  most  valuable  presented  by  Professor 
Smith  in  his  System»of  Surgery,  representing  a  combined  operation 
in  rhino-cheiloplasty.with  the  original  appearance  of  the  patient,  the 
steps  of  an  operation  devised  and  executed  by  Professor  Pancoast, 
and  the  result  obtained  as  exhibited  by  an  accurate  likeness  of  the 
patient  taken  sixteen  months  after  the  operation. 

History  of  the  Case. — The  history  of  this  case  will  serve  as  a 
type  and  study  of  similar  cases.  "A  man  aged  fifty-three  had  lost 
all  the  soft  parts  of  the  nose  and  whole  of  the  upper  lip,  from  the 
commissures  of  the  mouth  to  the  canine  fossa  of  each  side,  as  well 
as  the  septum  narium  and  the  turbinated  bones,  the  cavities  of  the 
antra  Higbmoriana  and  of  the  sphenoidal  sinuses  being  exposed. 


PIRATE   XIV. 

RHINOPLASTIC    AND    CHEILOPLASTIC    OPERATIONS. 

Fig.  1. — Appearance  of  John  Glover  prior  to  the  operations  of  Cheiloplasty 
and  Rhinoplasty. — After  Pancoast. 

Fig.  2. — View  of  his  face  with  the  chin  depressed.  The  mouth,  being  con- 
tracted into  a  rigid  orifice,  was  enlarged  laterally  by  the  storaato- 
plastic  operation  of  Dieffenbach  for  atresia  oris,  after  which  two 
flaps  were  made,  as  marked  in  the  lines  upon  the  cheeks,  so  as  to 
form  the  upper  lip. — After  Pancoast. 

Fig.  3. — Appearance  of  his  face  after  this  operation,  showing  the  position  of 
the  sutures  and  the  improvementin  the  mouth. —J/^er /'a?; coas?. 

Fig.  4. — Shows  the  steps  of  the  Ehinoplastic  operation  performed  iipon  him 
subsequently.  The  edges  of  the  nasal  cavity  beiug  freshened  by 
a  grooved  incision,  the  outline  of  the  new  nose  was  marked  on 
the  forehead  before  cutting  the  flap.  The  dots  indicate  the  posi- 
tion of  the  sutures. — After  Pancoast. 

Fig  5. — The  wound  in  the  forehead  being  closed  by  the  hare-lip  sutures,  the 
flap  was  reverted,  and  attached  in  the  groove  on  the  edge  of  the 
nasal  cavity  by  three  stitches  of  the  interrupted  suture,  which 
were  tied  over  little  rolls  of  adhesive  plaster,  after  Graefe's 
method.  The  edge  of  the  septum  is  also  attached  to  the  upper 
lip.  The  twist  in  the  pedicle  is  seen  in  the  root  of  the  nose. — 
After  Pancoast. 

Fig.  6.— An  accurate  likeness  of  John  Glover,  sixteen  months  after  the 
operation. — After  Pancoast. 


(1003) 


1004  ORAL  DISEASES  AND  SURGERY. 

His  appearance  with  his  month  closed  is  shown  in  Fig.  1.  The 
mouth,  when  opened,  presented  a  rigid  circular  orifice  three-fourths 
of  an  inch  in  diameter. 

"  Operation  of  Pancoast. — The  month  being  widened  after 
Dieffenbach's  method  (see  description  on  previous  page),  the  free 
surface  of  the  gum  was  freshened,  and  an  incision  was  then  made 
obliqueh^  upward  and  outward  for  a  quarter  of  an  inch  from  the 
point  where  the  gum  was  covered  by  integuments,  and  from  the  end 
of  this  another  cut  was  made  for  about  the  same  distance,  nearly 
parallel  with  the  incisions  for  widening  the  mouth,  but  inclined  a 
little  downward.  The  cheeks  being  now  loosened  from  the  gum  and 
malar  bone  by  incisions  on  the  side  of  the  mouth,  the  flap  of  skin 
and  subcutaneous  fatty  matter  was  raised  from  the  surface  of  the 
muscle  by  beginning  the  dissection  at  the  angle  next  the  nose,  Plate 
XIV.,  Fig.  2. 

"The  arterial  branches,  which  were  divided,  having  been  twisted, 
the  flaps  were  drawn  downward  and  forward  over  the  raw  surface  of 
the  gum,  and  fastened  together  with  the  hare-lip  suture,  Plate  XIA' ., 
Fig.  3,  the  inner  edge  of  the  rotated  flaps  being  thus  united  in  the 
middle  line  of  the  lip.  The  face  being  then  dressed  with  lint  wet 
with  lead-water  and  laudanum,  the  patient  recovered  in  about  two 
months.     The  nose  was  subse((uently  formed  as  follows: 

"The  hair  being  shaved  from  the  temple  and  forehead,  the  nasal 
orifices  closed  with  lint  to  prevent  the  entrance  of  blood,  and  the 
patient  lying  down  with  the  head  supported  by  a  pillow,  a  flap  was 
raised  from  the  forehead,  as  shown  in  Plate  XIV.,  Fig.  4,  the  skin 
being  divided  at  a  single  sweep  of  the  knife,  the  blade  of  which  was 
inclined  outward  so  as  to  cut  a  beveled  edge.  The  apex  of  the  flap, 
which  was  about  five-eighths  of  an  inch  wide,  rested  between  the 
eyebrows,  and  the  tongue-like  portion  which  was  to  form  the  columna 
nasi  extended  up  into  the  scalp.  The  base  of  the  flap  was  nearly 
three  inches  wide,  in  order  to  allow  for  its  subsequent  contraction. 
The  flap,  after  being  dissected  up,  was  then  turned  down  on  the 
left  side  and  wrapped  in  linen,  while  the  wound  in  the  forehead  was 
closed  by  four  interrupted  sutures,  after  which  the  flap  was  applied 
to  the  freshened  edges  of  the  new  lip  and  gums,  the  whole  being 
held  in  position  by  the  plastic  suture  before  described,  and  tied  over 
rolls  of  adhesive  plaster,  as  in  Graefe's  method,  Plate  XIV.,  Fig.  5. 
Union  having  occurred,  the  pedicle  of  the  flap  was  divided,  five 
weeks  subsequently,  by  passing  a  director  under  it,  after  which  it 
was  smoothly  fitted  down  to  the  roots  of  the  ossa  nasi,  in  a  cavity 


PLATE  XV. 

RHINOPLASTIC    OPERATIONS. 

Fig.  1. — Restoration  of  one-half  of  the  Nose  and  part  of  the  Cheek  by  a  flap 
taken  from  the  Forehead. — After  Pancoast. 

Fig.  2. — Side  view  of  the  same  with  the  flap  in  situ,  showing  the  arrangement 
oF  the  sutures  upon  the  cheek. — After  Pancoast. 

Fig.  3. — Likeness  of  a  Patient  operated  on  for  the  removal  of  a  Deformity 
caused  by  the  destruction  of  the  Hard  Palate,  Septum  Narium, 
and  all  the  soft  parts  of  the  Nose,  with  the  exception  of  the  lip 
and  columna,  these  being  distorted  and  fastened  to  the  lower  end 
of  the  ossa  nasi. — After  Pancoast. 

Fig.  4. — A  view  of  the  gap  left  in  the  Nose  of  Fig.  3,  after  the  dissection  of 
the  cicatrix  and  depression  of  the  tip  of  the  nose.  The  outlines 
of  the  flaps  cut  from  the  cheeks  to  fill  up  the  gap  are  also  shown. 
— After  Pancoast. 

Fig.  5. — A  side  view  of  the  same,  showing  the  application  of  the  Sutures  aud 
the  closure  of  the  wounds  left  in  the  formation  of  the  flaps. — 
After  Pancoast. 

Fig.  6. — A  front  view  of  the  same,  showing  the  arrangement  of  the  Twisted 
Sutures  to  both  the  nose  and  the  wounds  left  in  the  cheeks. — 
After  Pancoast. 


(1005) 


1006 


ORAL  DISEASES  AND  SURGERY. 


which  was  made  for  its  reception  by  excising  a  portion  of  the  sub- 
jacent integuments.  By  the  twelfth  clay  union  was  perfect,  and  the 
patient  left  the  hospital  so  much  improved  that,  sixteen  months 
subsequently,  his  likeness  was  taken,  as  represented  on  Plate  XIV., 
Fig.  Q.''— Smith. 

Fig.  330  exhibits  a  case  which  was  of  much  interest  to  the  author, 
inasmuch  as  the  defect  deformed  the  person  of  a  fine-looking  lady, 
and  had  twice  been  attempted  to  be  cured  by  a  plastic  section 
from  the  cheek  ;  the  flap  in  both  instances  had  sloughed.  Examin- 
ing the  diagram,  an  irregular  Y-shaped  break  is  seen  to  exist  in  the 
right  ala;  this  had  been  produced  by  the  improper  application  of 
caustics  for  the  cure  of  a  supposed  cancer.  Tiie  character  of  opera- 
tion seen  in  the  diagram  yielded  a  most  satisfactory  result:  this 
consisting  in  the  employment  of  a  double  Y-incision,  conjoined  with 
a  second  loosening  of  the  ala  at  its  external  inferior  angle  from  the 
cheeks;  these  cuts  made,  the  ala  was  slipped  toward  the  mesial 
line  and  fixed  in  its  new  position  by  a  pin.  Passing  now  to  the  com- 
paratively lax  nostril,  a  delicate  hare-lip  pin  was  passed  through 
the  apices  of  the  two  lesser  triangles,  and  by  means  of  the  figure-of- 
8  ligature  these  apices  were  brought  into  contact, 
thus  necessarily  securing  a  proper  curvature  to  the 
free  border  of  the  nostril. 

Referring  to  Plate  XIII.,  Fig.  1,  is  seen  the  front 
view  of  a  patient  operated  on  l)y  Dr.  Watson,  in  the 
Xew  York  City  Hospital,  for  the  relief  of  a  large 
ulcer,  accompanied  with  syphilitic  caries  of  the 
frontal  l)one  ;  the  ulcer  "  is  represented  with  thick- 
ened and  inverted  edges,  and  as  retaining  a  portion 
of  the  necrosed  bone.  A  fistulous  orifice  is  also  de- 
scribed as  existing  at  the  upper  borders  of  each  orbit, 
with  another  in  the  left  temple,  through  which  pus 
escaped  freely.  The  upper  eyebrows  and  upper 
ej'elids  are  shown  as  sliglitly  elevated  and  deformed 
by  the  adventitious  adhesions  existing  around  these 
fistulse." 

Fig.  3  represents  the  lines  of  incision  practiced  for  the  securing 
of  flap-tissue  to  cover  this  ulcer,  together  with  the  approximation 
secured,  and  the  appearance  of  sutures  in  place. 
Fig.  2  exhibits  the  relief  secured  by  the  operation. 
Another  manner  of  treating  facial  ulcer,  or  indeed  any  ulcer,  con- 
sists in  the  transplantation  of  particles  of  skin,  as  referred  to  on  a  pre- 


Fio.  330. 


RHINO-  AND  RHINO-CHEILOPLASTIC  OPERATIONS.  1007 

vious  page.  These  islands  serve  as  points  of  cicatrization,  and  not 
unfrequently  succeed  most  happily  in  covering  an  ulcer,  and  limit- 
ing to  marked  extent  the  boundaries  of  a  cicatrix.* 

An  accident  occasionally  met  with  by  a  class  of  persons  who  in- 
dulge in  street-brawls,  consists  in  the  loss  of  the  tip  of  the  nose  by 
the  teeth  of  an  antagonist. 

Fig.  331  affords  an  idea  of  the  appearance  of  the  part  after  such 
an  accident. 

To  treat  such  a  case  implies,  first,  consideration  of  the  state  of 
the  wound.    The  incisor  teeth  of  people  differ  very  markedly,  being 
in  some  of  such  knife-like  edge  that  a  wound  made 
by  them  would  really  represent  the  ordinary  incised  -^^*^- 

wound,  and  might  be  expected  to  heal  with  little  or 
no  slough  ;  teeth  there  are  on  the  other  hand 
known  ordinarily  as  double,  where  the  surface  is 
found  so  broad  and  jagged  that  sloughing  to  a  greater 
or  less  extent  would  necessarily  associate  with  any 
wound  made  by  them.  This  matter,  however,  is  to 
be  epitomized  by  remarking  that  such  a  wound  is 
ready  for  operation  when  the  surface  is  that  of  the 
ulcer  described  on  other  pages  as  healthy.  ^ 

In  the  case  of  a  portion  of  nose  bitten  off,  it  is  good 
practice,  if  the  piece  is  quickly  found  and  is  not  too  much  injured, 


*  The  study  of  the  subject  of  transplantation  of  tissue  has  recently  received 
fresh  imj)etus  from  the  experiments  which  have  been  made  in  the  direction 
of  attempts  to  compel  independent  islands  of  skin  to  unite  with  and  live  upon 
an  ulcerated  surface  without  the  support  of  a  pedicle.  The  nutrition  of  such 
a  piece  of  transplanted  sliin,  and,  in  fact,  the  immediate  union  of  any  trans- 
planted flap,  necessitates  the  rapid  passage  of  vessels  across  the  intervening 
space  and  the  production  of  but  little  intermediate  tissue.  The  formation  of 
new  blood-vessels  in  tissue  is  a  subject  so  wonderful  that  it  is  well  worthy  of 
careful  study.  At  some  point  on  an  existing  vessel  the  wall  dilates  ;  a  pouch 
is  formed  ;  it  deepens,  and  a  blind  canal  results.  At  the  same  time,  at  a  point 
not  far  distant  from  the  first,  a  similar  action  is  going  on,— one  divertieuhnn 
projects  backward,  the  other  forward,  each  taking  its  course  in  the  direction 
of  the  new  tissue  to  be  nourished  or  formed  ;  they  extend,  meet ;  the  inter- 
vening walls  which  closed  their  ends  are  removed,  and  a  continuous  arch  is 
formed,  through  which  the  blood  freely  courses.  Thus  at  every  point  these 
little  otfshoots  or  arms,  microscopic  in  size,  unite  with  similar  ones  from  the 
same  or  adjoining  vessels,  until  multitudes  of  little  arches  and  natural  anas- 
tomoses are  formed,  and  nutrition  is  accomplished,  every  step  being  taken 
with  precision,  regularity,  and  dispatch.     Thus  marvelous  are  the  actions 


1008  ORAL  DISEASES  AND   SURGERY. 

to  stitch  and  bind  it  in  position.  Nothing  can  lie  lost  by  so  doing;, 
and  an  easy  repair  may  possibly  be  secured.  Should,  however,  such 
result  not  ensue,  the  part  is  to  be  replaced  by  modifications  of  some 
of  the  various  operations  suggested.  Or,  most  conveniently,  it  is  to 
be  done  from  a  flap  secured  from  the  lips,  as  shown  in  the  diagram  ; 
this  flap,  shaped  to  fit  the  part  lost,  is  twisted  on  its  pedicle,  and 
attached  after  the  usual  manner.  The  gap  left  in  the  lip  is  simply 
an  expression  of  hare-lip,  and  is  to  be  so  treated.  (See  Operations 
for  Hare-lip.) 

From  the  studies  and  illustrations  offered,  it  is  to  be  taken  for 
granted  that  the  ingenuity  of  the  practitioner,  directed  by  tbe  hints 
afforded,  will  enable  him  to  meet  such  varying  indications  as  may 
from  time  to  time  be  met  with.  The  subject  is  a  very  interesting 
one,  and  will  well  repay  the  attention  given  to  it. 

constantly  taking  place  in  our  bodies  to  subserve  the  process  of  repair;  and 
although  man's  capacity  for  the  reproduction  of  lost  tissue  is  infinitely  less 
than  that  of  lower  beings,  yet  all  of  us  must  frequently  be  astonished  at  the  ex- 
tent of  reparative  power  exhibited  by  nature.  As  we  descend  the  scale  to  crea- 
tures incapable  of  self-defense  or  self-preservation,  the  provision  for  the  sus- 
tenance of  existence  becomes  more  marked,  until,  in  protozoa,  self-mutilation 
is  but  a  common  occurrence  in  case  of  danger,  repair  being  so  active  that  a 
short  time  suffices  to  replace  any  member  which  may  thus  have  been  cut  off. 
Man,  endowed  with  powers  of  reasoning  and  defense,  requires  such  provisions 
to  a  correspondingly  less  degree,  and  in  him  we  find  that  repair  exists  in  its 
least  expression.  Still,  with  our  advancing  knowledge,  we  may  hope  to  assist 
nature  even  in  this  process,  as  exampled,  for  instance,  in  the  reproduction  of 
bone  from  preserved  periosteum. — Clinical  Report  by  Dr.  Ue  Forkest 
Will  ARC. 


CHAPTER    XLIX. 

PALATINE    DEFECTS   AND    THEIR   TREATMENT. 

In  the  treatment  of  any  palatine  defect,  the  6rst  consideration 
necessarily  is  to  be  of  its  cause  and  condition.  Thus,  it  will  be 
found  that  such  defects  or  deficiencies  may,  by  influencing  circum- 
stances, require  treatment  so  modified  or  changed  as  to  seem,  in 
cases  apparently  similar,  quite  at  variance  with  each  other. 

For  example,  take  two  perforations  exposing  the  nares;  one  con- 
genital, the  other  the  result  of  disease.  In  the  first  of  these  cases 
any  operation  or  appliance  which  would  seem  to  promise  relief 
might  be  adopted;  in  the  second  we  might  justly  pause  at  any  inter- 
ference. No  one  in  his  senses  would  attempt  the  operation  of 
staphyloraphy  on  a  patient  laboring  under  acute  syphilis,  or  where 
a  mercurial  course  had  so  broken  down  the  crasis  of  the  blood  as  to 
make  a  union  by  the  first  intention  impossible,  or  even  doubtful. 
No  more  would  one  be  justified  in  attempting  this  or  any  otlier  of 
the  operations  of  expediency,  with  the  constitutional  conditions 
adverse  to  success,  than  he  would  be  justified  in  avoiding  the 
responsibility  w^here  such  influencing  associations  were  favorable. 

Cleft  Palate. — The  condition  known  as  cleft  palate,  to  which 
we  at  once  pass,  may,  from  its  exceeding  frequency,  be  the  first  to 
claim  attention.  A  cleft  maybe  partial  or  complete;  that  is,  there 
may  be  a  simple  lengthwise  division  in  that  portion  of  the  mouth 
known  as  the  soft  palate,  or  the  cleft  may  be  so  extensive  as  to  ex- 
tend from  the  uvula  to  the  lip,  a  fissure  separating  both  hard  and 
soft  parts.  The  first  of  these  two  conditions  is  found  perhaps  most 
frequently  as  the  result  of  disease ;  the  latter  is  nearly  always  con- 
genital. Indeed,  I  do  not  recall  a  single  case  where  I  have  met 
complete  fissure  as  the  result  of  disease.  I  have  treated  fissures 
produced  by  syphilis  where  there  was  a  break  both  in  the  bone 
and  in  the  soft  palate,  but  never  that  I  remember  where  a  coexistent 
break  existed  in  the  continuity  of  the  lip. 

Fissure  of  the  hard  palate  the  result  of  disease,  differs,  however, 
from  the  congenital  form  in  a  particular  which  I  think  would  scarcely 

63  (1009) 


1010  ORAL  DISEASES  AND  SURGERY. 

allow  of  the  surgeon's  being  deceived.  A  fissure  the  result  of  dis- 
ease exhibits  an  irregular  break  in  the  continuity  of  one  or  both 
palatine  processes;  a  fissure  having  congenital  origin  exhibits,  so 
far  as  my  experience  goes,  the  deficiency  harmonious  to  the  line  of 
contiguity  or  in  the  palatine  raphe, — this  at  least  as  the  rule. 

Let  us  first  consider  the  condition  and  treatment  of  the  congeni- 
tal cleft,  A  child  is  born,  toward  whose  mouth  attention  is  first 
directed  either  by  the  nasal  character  of  its  cry,  or,  a  little  later,  by 
its  inability  to  take  the  breast  properly;  or  the  condition  is  marked, 
perhaps,  by  the  break  continuing  through  the  lip,  giving  the  de- 
formity which  we  have  studied  as  hare-lip. 

When  a  child  is  thus  unfortunate,  and  the  attention  of  the  sur- 
geon is  called  to  the  case,  a  single  question  presents  itself,  namely, 
how  the  deformity  is  to  be  corrected  :  if  it  be  suffered  to  exist,  every 
day  will  increase  the  difficulty  of  the  cure,  that  is,  so  far  as  the  most 
formidable  part  of  the  operation  is  involved,  while  if  its  correction  be 
at  once  attempted,  the  prospect  of  complete  success  is  very  great. 

Fissure  of  the  hard  palate  has  generally  been  deemed  irremediable, 
so  far  as  operative  means  are  concerned,  and  the  surgeon  has  been 
taught  to  consider  his  whole  duty  done  in  describing  to  the  parents 
the  mechanical  method  which  in  after-life  was  to  conceal  and  correct 
the  trouble  of  his  patient.  Now,  in  this  chapter  I  shall  present  a 
remedial  surgery  which  is  as  practicable  and  feasible  as  any  other 
of  the  operations  of  expediency,  and  perhaps  I  am  justified  in  going 
so  much  further  as  to  say  that  the  modes  of  procedure  will  be  found 
much  more  promising  than  the  majority  of  such  operations.  Through 
the  proper  application  of  mechanical  allied  with  the  more  strictly 
surgical  means,  I  have  not  unfrequently  succeeded  in  effecting 
changes  in  the  young  maxillary  bones,  a  simple  description  of  which 
miglit  cause  my  veracity  to  be  doubted  ;  and  yet  this  ability  to  effect 
such  changes  must  become  very  plain  to  us,  if  for  a  single  moment 
we  pause  to  consider  the  difference  between  the  composition  of  the 
young  and  that  of  the  old  bone.  Young  bone,  or  bone  at  birth,  as 
is  well  known,  is  almost  if  not  quite  half  made  up  of  animal  material ; 
while  in  the  osseous  structure  of  the  adult  there  is  excess  in  the 
lini}'  or  unyielding  material,  from  seventy-five  to  perhaps  quite 
eighty-five  per  cent. 

To  illustrate  more  familiarly  this  yielding  constituent  of  bone, 
let  me  refer  to  the  old  experiment  of  the  maceration  of  bone  in  dilute 
muriatic  acid.  We  know  that  if  we  subject  a  bone  to  the  action  of 
this  acid  for  one  or  two  weeks,  we  may  tie  a  rib  like  a  whip-cord. 


PALATINE  DEFECTS  AND    THEIR    TREATMENT.    1011 

t 

Now,  we  do  this  simply  by  reducing  an  old  bone  to  somewhat  the 
condition  of  a  young  one.  I  have  removed  a  rib  from  a  living  young 
cat,  and  manipulated  it  in  this  same  whip-cord  manner.  I  have  per- 
ceptibh^  bent  the  femur  of  a  young  child;  but  no  one,  I  imagine, 
ever  performed  such  a  manipulation  on  the  healthy  femur  of  the 
adult.  You  may  take  an  inferior  maxillary  bone,  even  in  a  child 
of  fifteen  years,  where  the  projection  of  the  chin  is  so  great  as  to  pro- 
duce deformity,  and  with  a  properly-constructed  vertico-mental  elas- 
tic sling  you  may,  in  a  period  varying  from  three  weeks  to  as  many 
years,  so  change  the  angle  of  the  bone  as  to  do  away  entirely  with 
the  deformity.  You  may  take  the  projecting  myrtiform  border,  and 
through  the  instrumentality  of  the  occipito-alveolar  sling  in  quite 
a  short  period  compel  it  to  a  natural  articulation.  On  this  known 
yielding  character  of  the  young  bone,  therefore,  operations  for  the 
correction  of  congenital  fissures  of  the  hard  palate  may  be  founded. 

A  congenital  fissure  of  the  hard  palate  may  be  corrected  instantly, 
or  the  cure  may  be  effected  slowly.  The  first  of  these  procedures  is 
applicable  to  such  cases  as  present  but  a  limited  separation  of  the 
bones;  the  latter,  when  the  fissure  has  considerable  width. 

The  operative  procedure  for  the  immediate  cure  is  as  follows:  an 
instrument,  a  modification  of  the  Hoey  clamp,  ordinary  arterial 
compressor,  or  a  Hainsby  compress,  is  to  be  made  by  so  arranging 
the  pads  that  they  shall  apply  to  the  sides  of  the  jaws  and  allow  of 
the  force  being  so  directed  that  the  pads  can  be  approximated  with- 
out undue  facial  pressure.  The  clamp  of  Hoey,  it  will  be  seen, 
needs  alteration  only  so  far  as  the  pads  are  concerned,  and  is  quite 
easy  of  adjustment  to  this  purpose. 

The  instrument  ready  (the  patient  being  in  proper  condition),  the 
operator  commences  by  paring  the  soft  parts  and  bone  on  both  sides 
of  the  fissure,  beginning  on  the  approximal  faces  of  the  palate-bones, 
and  cutting  forward  to  the  alveolar  face  of  the  chasm.  This  part 
of  the  operation  completed,  the  little  patient  may  be  allowed  to 
rest  until  the  bleeding  ceases.  The  next  step  is  to  re-etherize  and 
apply  the  compressor,  the  curved  pads  embracing  the  buccal  faces 
of  the  alveolar  arch ;  by  now  gradually  turning  the  screw  of  the 
instrument,  the  yielding  bones  are  brought  together.  The  next  and 
last  step  in  the  operation  is  to  retain  the  parts  in  position  by  the 
use  of  compresses  placed  upon  and  below  the  malar  bones,  and 
secured  by  adhesive  strips  applied  as  in  the  occipito-labial  cravat 
of  Mayo. 

It  may  be  urged  against  these  manipulations  that  they  are  formi- 


1012  OEAL  DISEASES  AND  SURGERY. 

V 

dable  and  too  heroic ;  that  fractures  may  result,  etc.  On  these  points 
the  surgeon  must  decide  for  liiniself.  I  can  only  answer  that,  if 
carefull}^  performed,  it  is  not  a  dangerous  operation  ;  fracture  of  the 
bone,  even  if  it  should  occur,  would  be  of  little  consequence,  as  the 
parts  have  to  be  kept,  as  it  were,  in  splints,  and  consequently  the 
treatment  of  the  one  would  be  the  treatment  of  the  other.  The  most 
marked  risk  is  from  inflammation  that  may  be  provoked  ;  but  a  sur- 
geon not  unfrequently  has  to  run  far  greater  risk  for  even  a  less 
result. 

Another  mode  of  securing  the  same  end,  which  is  entirely  divested 
of  formidable  risk,  is  as  follows  :  take  a  circle  of  india-rubber  tubing, 
the  circumference  of  which  shall  be  about  one-third  or  one-half  that 
of  the  child's  head;  next  prepare  two  firm  compresses,  of  a  size 
adapted  to  the  case  under  treatment ;  place  these  pads  or  comi)resses 
one  on  either  cheek,  in  such  position  as  will  give  them  their  rest  on 
the  buccal  faces  of  the  alveolar  arch.  Having  secured  them  in  place 
by  one  or  more  delicate  strips  of  adhesive  plaster,  take  up  the  ring 
of  rubber  and  pass  it  around  the  cervico-labial  diameter  of  the  head. 
Passing  over  the  compresses,  it  will  thus  exert,  as  is  seen,  a  gradual 
pressure,  serving  to  push  the  bone  toward  a  common  centre,  this 
centre  being  the  mesial  line  of  the  palatine  arch.  This  process  is  a 
gradual  one;  but,  if  the  patient  is  yuung,  I  think  it  will  be  found  to 
succeed  ;  the  only  real  objection  to  the  manipulation  is  the  constant 
care  necessary  to  prevent  excoriation  of  the  tender  skin. 

When,  by  this  procedure,  the  bony  parietes  have  been  brought 
into  contact,  the  operation,  so  far  as  the  hard  palate  is  concerned,  is 
completed  by  simply  paring  the  folds  of  the  mucous  membrane.  It 
may  or  may  not  be  necessary  to  coaptate  them :  if  the  bones  have 
been  brought  very  close  together,  the  granulations  will  alone  be 
sufficient  to  bridge  the  slight  remaining  chasm. 

In  either  of  these  operations  it  is  seen  that  the  break,  both  in  the 
soft  palate  and  the  lip,  is  not  remedied.  It  is  well,  I  think,  not  to  at- 
tempt the  cure  of  the  lip  until  the  patient  has  entirely  recovered  from 
the  foregoing  operation.  It  may  then  be  performed,  and,  if  done 
according  to  the  rules  given,  will  secure  to  the  patient  a  lip  so 
perfect  that,  in  adult  life,  little  or  perhaps  no  mark  of  an  operation 
will  exist.  The  operation  fur  the  cleft  in  the  soft  palate  must  be 
left  to  a  period  later  in  life,  for  reasons  presently  to  be  alluded  to. 

These  suggestions  for  the  cure  of  cleft  in  the  hard  palate  were,  I 
thought,  original  with  myself, — though  it  is  of  slight  consequence 
who  invents  an  operation,  so  that  it  be  good ;  but  in  the  periscopic 


PALATINE  DEFECTS  AND    THEIR    TREATMENT.    1013 

department  of  the  Dental  Coi^mos  I  find  the  following  extract,  taken 
from  the  Australian  Medical  Record  and  Dublin  Medical  Press, 
which  shows  that  the  operation  was  conceived  by  another  before  it 
presented  itself  to  my  mind.  The  extract  is  a  short  one,  and  so 
apropos  to  the  matter  that  I  shall  take  the  liberty  to  present  it 
entire: 

^'Pressure  in  the  Treatment  of  Cleft  Palate. — I  am  not  aware," 
says  the  author,  "that  the  subject  of  using  pressure  in  treating  fis- 
sure of  the  palate  has  been  before  suggested.  I  am  inclined  to  think 
that  it  has  not;  for  when  the  plan  first  presented  itself  to  my  mind, 
in  1851,  T  carefully  examined  French,  German,  English,  and  Ameri- 
can works  to  see  whether  it  had.  I  was  first  led  to  try  it  on  the 
dead  body  of  a  child,  which  had  died  three  weeks  after  birth.  The 
fissure  was  longitudinal,  and  large  enough  to  admit  the  extremity 
of  the  little  finger;  fissure  of  the  lip  also  existed.  By  means  of  a 
pair  of  clamps,  the  sides  of  the  fissure  were  brought  readily  in  con- 
tact, without  any  fracture  or  displacement  of  the  bones ;  the  only 
fault  was  that  the  gums  of  the  upper  jaw  were  within  those  of  the 
lower;  but  nature  would  modify  this  as  the  living  child  grew  up; 
the  use  of  pressure  on  the  lower  jaw  would  remove  a  great  deal  of 
this  deformity;  of  course  the  amount  of  deformity  would  depend  on 
the  size  of  the  fissure  in  the  palate.  I  several  times  repeated  the 
experiments  on  young  dogs,  removing  a  piece  of  the  palate-bone  by 
means  of  Hey's  saw,  and  then  applying  the  pressure.  The  animals 
did  well. 

"  The  operation  should  be  performed  as  early  as  possible  after 
birth,  when  the  bones  are  in  their  softest  condition.  The  following 
is  the  plan  which  I  would  suggest:  the  edges  of  the  fissure  having 
been  pared,  the  superior  maxillary  bones  should  be  embraced  by  a 
horseshoe-shaped  clamp,  with  a  shelf  on  its  lower  border  to  receive 
the  gums  and  prevent  it  slipping.  It  should  be  padded  with  india- 
rubber  or  some  other  material,  to  prevent  the  germs  of  the  teeth  being 
injured.  The  clamp  should  work  on  a  joint,  and  possess  arms.  It 
may  be  said  to  resemble  a  large  pair  of  pincers  with  horseshoe-shaped 
blades.  A  screw  may  be  attached  at  the  extremities  of  the  handles, 
for  the  purpose  of  bringing  the  blades  in  contact,  or  the  hands  may 
be  used:  the  former  would  be,  I  think,  preferable,  as  the  force  could 
be  applied  gradually,  and  not  be  likely  to  be  carried  too  far.  It  may 
also  be  employed  in  grown-up  children,  when  the  bones  are  so  widely 
separated  as  to  render  it  difficult  to  get  soft  parts  enough  to  close 
the  opening,  but  in  a  gradual  manner  and  at  intervals  more  or  less 


1014  ORAL  DISEASES  AND   SURGERY. 

prolonged,  according  to  the  amount  of  pain  it  excites.  If  it  were 
used  suddenly  it  might  produce  inflammation,  and  subsequently 
abscess,  which  would  prove  troublesome  to  treat.  From  the 
foregoing  it  will  be,  I  hope,  understood  that  the  younger  the 
child  the  safer  the  operation  is  likely  to  prove,  and  tliat  even  in 
grown-up  children  it  may  be  adopted,  with  precaution,  with  decided 
benefit. 

"The  pads  and  the  ledge  to  rest  the  teeth  upon  should  be  made 
to  slide  in  the  sides  of  the  clamp  :  the  former,  that  the  pressure 
may  be  directed  on  any  part  of  the  bones ;  the  latter,  that  the 
edges  of  the  teeth  may  rest  on  it,  without  the  pressure  being 
directed  either  too  high  or  too  low,  but  at  the  point  where  the 
palate-bone  joins  the  superior  maxillary." 

We  pass  now  to  the  consideration  of  the  treatment  of  the  fissure 
in  the  soft  palate.  This  operation  is  known  as  staphyloraphy,  a 
term  derived  from  two  Greek  words,  which  signify  suture  of  the 
uvula.  As  generally  practiced,  it  is  rather  difficult  of  performance, 
and  so  frequently  unsuccessful  that  surgeons  seem  disposed  to  avoid 
the  responsibility  of  it.  I  propose  here  to  suggestfor  consideration 
a  new  mode  of  performing  the  operation,  which  renders  the  manipu- 
lations as  easy  of  accomplishment  as  by  the  old  mode  they  are 
tedious  and  diflBcult. 

Preparation  of  the  Patient. — For  weeks  before  it  is  designed  to 
perform  this  operation,  preparations  are  made  for  it  by  subjecting 
the  parts  to  such  daily  manipulations  as  shall  educate  to  forbearance 
the  natural  sensibility  of  the  fauces.  In  the  absence  of  such  prelimi- 
nary manipulation,  the  retchings  and  spasmodic  twitchings  are  such 
as  to  render  a  proper  performance  of  the  operation,  without  the  use 
of  an  anassthetic,  almost  an  impossibility.  With  such  education,  the 
parts  will  be  found  to  assume,  in  a  reasonable  time,  quite  a  stoical 
indifference  to  even  severe  irritants.  This  forbearance  is  secured 
by  roughly  fingering  the  part  daily.  I  think  it  is  not  amiss  to 
pass  occasionally  the  point  of  the  tenaculum  through  the  parts  to 
be  operated  upon.  I  never  knew  the  trifling  wound  to  give  any 
trouble ;  and  the  double  advantage  is  gained,  if  the  part  be  put  on 
stretch,  of  securing  an  estimate  of  the  capability  of  the  velum  to 
be  brought  to  the  mesial  line, — an  important  item  in  the  operation, 
as  will  be  easily  appreciated.  Some  surgeons  are  in  the  habit  of 
daily  tickling  the  parts  with  a  fine  brush;  this,  I  should  suppose, 
would  answer  a  very  good  purpose.     A  very  admirable  idea,  and  a 


PALATINE  DEFECTS  AND    THEIR    TREATMENT.   1015 

most  successful  one,  is  to  have  made  an  obturator,*  which  shall 
extend  back  to  the  palate-border,  or  nearly  to  it.  This  is  to  be 
placed  in  the  mouth,  and,  as  soon  as  the  irritability  it  produces  is 
so  far  overcome  as  to  permit  of  its  permanent  retention,  the  bands 
attached  to  it  are  to  be  clasped  firmly  about  the  necks  of  the  teeth, 
and  it  is  worn  continuously  for  one  or  two  months.  When  the  parts 
have  thus  submitted  to  the  presence  of  an  obturator,  they  will  be 
found  quite  ready  for  any  operation. 

On  the  evening  before  the  day  of  operation,  let  a  saline  cathartic 
be  given  the  patient,  particularly  if  he  be  robust  and  strong.  The 
meal  immediately  preceding  the  performance  should,  I  think,  always 
be  a  substantial  one,  for  it  is  to  be  remembered  that  the  patient  is 
to  have  little  to  eat  for  some  time. 

In  operating  on  a  depressed  and  anismic  patient,  let  his  defi- 
ciency in  vital  forces  be  first  considered,  and,  as  far  as  possible,  let 
it  be  corrected.  If  such  attention  is  neglected,  we  will  be  almost 
sure  to  make  a  failure  :  the  parts  will  not  unite.  Exercise  in  the 
open  air,  generous  living,  and  the  iron  tonics  may  be  prescribed. 
To  sum  up  all  in  a  single  sentence,  the  preliminary  treatment  must 
meet  the  indications  of  each  particular  case.  If,  for  example,  you 
should  operate  on  a  scorbutic  patient,  or  a  patient  disposed  to 
purpura,  without  correcting  such  dyscrasia,  you  would  be  no  more 
likely  to  gain  unioQ  of  the  parts  brought  together  than  in  an  opera- 
tion on  the  cadaver. 

The  surgical  anatomy  of  the  part  must  be  fully  understood.  So 
much  of  success  depends  on  a  thorough  knowledge  of  the  muscular 
relation  to  the  cleft  that  such  acquaintance  would  give  a  success  where 
otherwise  a  failure  would  be  sure  to  result.  This  anatomy  we  may 
study  before  taking  up  the  steps  of  the  operation. 

To  get  a  correct  idea  of  the  soft  palate,  we  should  commence  the 
study  of  it  by  first  carefully  examining  the  .parts  on  the  living  sub- 
ject. When  we  look  into  a  living  mouth,  we  see  an  arch  stretching 
from  every  portion  of  the  alveolar  edge  backward  and  inward,  toward 
the  fauces,  terminating  in  a  tongue  or  uvula,  pendent  in  a  horizontal 
direction  from  its  centre.  One-half  of  this  arch  is  seen  to  be  fi.xed, 
the  other — the  posterior  half — is  seen  to  be  in  almost  constant 
motion.  If  now  the  finger  is  carried  into  the  mouth,  the  fixed  part 
is  found  to  correspond  with  the  boundaries  of  the  palatine  faces  of 


*  A  description  of  this  instrument  and  of  its  proper  use  will  hereafter  bo 


riven. 


1016  ORAL  DISEASES  AND  SURGEBY. 

the  raaxillarj  and  palate  bones ;  that  is,  for  a  certain  extent,  you 
feel  that  the  parts  are  solid,  as  if  the  finger  passed  over  an  arch  of 
bone  which  might  be  covered  alone  by  mucous  membrane ;  and  this 
is  in  fact  about  the  case.  The  finger  traverses  the  anterior  bony 
border  of  the  mouth,  or  the  hard  palate.  As  now  the  finger  is 
passed  backward,  it  falls  over  a  hard  ridge  upon  parts  that  are  soft 
and  yielding;  this  hard  ridge  is  the  posterior  face  of  the  palate- 
bone,  and  terminates  the  hard  palate.  The  part  upon  which  the 
finger  has  fallen  is  the  veil  or  soft  palate,  the  part  that  was  observed 
to  be  movable.  This  is  the  part  in  which  occurs  the  rent,  or  cleft, 
for  the  cure  of  which  is  demanded  the  operation  we  arc  about  to 
consider. 

The  mobility  of  this  part,  which  pertains  to  its  function,  depends, 
as  may  be  anticipated,  on  an  associated  muscular  structure.  To 
study  properly  this  structure,  which  it  is  all-important  to  understand 
and  appreciate  practically,  the  student  should  take  up  the  scalpel  and 
pass  to  the  cadaver;  it  is,  perhaps,  only  by  dissecting  that  a  really 
satisfactory  idea  of  these  muscles  can  be  secured, — that  is,  as  pertains 
to  that  kind  of  knowledge  which  gives  confidence  when  we  come  to 
perform  operations  upon  the  part. 

The  external  coat  or  covering  which  we  see  on  every  mouth, 
living  or  dead,  is  the  mucous  membrane, — simply  the  continuation 
of  that  which  covers  the  hard  palate;  but  while  in  the  case  of  the 
hard  palate  w^e  find  all  the  underlying  structure  osseous,  in  the  soft 
palate  we  discover  this  deep  tissue  to  be  made  up  exclusively  of 
muscular  tissue, — at  least  so  far  as  a  surgical  anatomy  is  concerned, 
or  as  it  serves  our  purpose  here  to  study  it. 

Commencing  with  the  mesial  line,  we  can  dissect  out  the  attach- 
ment of  five  muscles,  each  of  which  is  of  course  duplicated  on  the 
opposite  side,  and  each  of  which  has  such  relation  to  this  mesial 
line  that,  in  case  of  cleft  or  split,  it  serves  more  or  less  to  draw 
away  the  parts  postero-laterally. 

These  muscles,  mentioned  in  the  order  of  their  signification  to 
this  lateral  displacement,  and  consequently  in  their  relation  to  the 
operation  of  stapliyloraphy,  are  the  tensor  palati,  palato-glossus, 
levator  palati,  palato-phuryngeus,  motores  uvulae.  Of  all  these 
muscles  the  tensor  palati  plays  the  most  important  part,  and  is 
therefore  entitled  to  the  closest  consideration. 

This  muscle  arises  from  the  scaphoid  fo.ssa  at  the  root  of  the 
internal  pterygoid  plate,  from  the  anterior  surface  of  the  Eustachian 
tube,  and  from  the  spinous  process  of  the  sphenoid  bone.     If  you 


PALATIXE  DEFECTS  AND    THEIR    TREATMENT.    1017 

carry  your  finger  (in  your  own  mouth)  back  to  the  wisdom-tooth  of 
the  superior  jaw,  and  let  it  drop  over  and  back  of  this  tooth,  it  will 
fall  on  the  tuberosity  of  the  maxillary  bone ;  carry  it  now  half  an 
inch  farther  back,  and  it  will  come  to  a  second  prominence  ;  this  is 
the  hamular  process  of  the  pterygoid  plate  of  the  sphenoid  bone. 
Now,  the  tensor  palati  muscle  descends  from  the  origin  of  which 
we  have  just  informed  ourselves,  and,  meeting  this  hamular  process, 
it  winds — as  a  tendon — around  it,  and  then,  by  a  fan-like  expansion, 
spreads  itself  over  the  soft  palate.  Its  action  is  evident :  it  expands 
the  palate  laterally. 

To  perform  successfully  the  operation  for  cleft  palate,  it  is  perhaps 
desirable,  in  every  case,  that  the  strain  made  by  this  muscle  should 
be  taken  off.  A  moment's  reflection  will  show  us  that  the  action  of 
the  muscle,  in  case  of  a  cleft,  would,  w'hen  the  parts  were  brought 
together,  be  much  increased  over  its  natural  capability,  not  only 
because  it  would  be  put  considerably  on  the  stretch,  but  also  because 
such  stretch  would,  more  than  likely,  excite  it  to  a  spasmodic  con- 
traction. The  muscle  of  course  is  then  to  be  divided  ;  and  we  may 
as  well  here,  as  anywhere,  consider  the  easiest  point  at  which  such 
preliminar}'  operation  can  be  done. 

It  is  remarked  that  the  muscle  is  found  winding — as  a  tendon — 
around  the  hamular  process.  It  winds  from  the  back,  and  out- 
wardly, inward,  and  forward,  so  that  just  in  front  of  the  process, 
between  it  and  the  tuberosity,  is  the  place  at  which  its  section  may 
be  best  performed  ;  there  are  here  no  important  vessels  to  be 
wounded,  if  we  except  the  posterior  palatine  artery  and  nerve,  apd 
these  hug  the  base  of  the  tuberosity  so  closely  that  it  would,  I  think, 
have  to  be  a  very  badly-managed  knife  that  should  interfere  with 
either  of  them.  The  cut  should  be  a  little  oblique.  The  inter- 
ference with  function,  as  in  most  cases  of  myotomy,  or  tenotomy, 
would  be  of  course  but  temporary.  The  action  of  the  muscle  would 
be  found  recovered  quite  as  soon  as  our  cleft  operation  would  be 
ready  for  it. 

The  next  most  important  muscle  is  the  palato-glossus ;  this  is 
simply  the  anterior  half-arch,  the  constrictor  isthmii  faucium.  It 
arises,  as  will  be  seen,  from  the  soft  palate  on  either  side  of  the 
uvula,  and,  passing  outward,  is  inserted  into  the  sides  of  the  tongue, 
blending  with  the  fibres  of  the  stylo-glossus  muscle. 

The  palato-pharyngeus  arises  from  the  soft  palate  by  an  expanded 
fasciculus,  and,  passing  outward,  goes  to  be  inserted  into  the  poste- 
rior borders  of  the  thyroid  cartilage.     These  muscles  constitute  the 


1018  ORAL  DISEASES  AND  SURGERY. 

posterior  half-arches.  Section  of  the  palato-pharyngeus  and  the 
palato-glossus  is  to  be  made  through  the  substance  of  the  muscles, 
and  is  accomplished  simply  by  nicking,  somewhat  deeply,  the  arches, 
— four  cuts,  one  to  each  arch.  These  nicks  are  best  made  with 
scissors. 

The  levator  palati  muscle  arises  from  the  petrous  portion  of  the 
temporal  bone,  passes  into  the  interior  of  the  phar3nix,  and  then 
descends  obliquely  downward  and  inward,  spreading  its  fibres  out 
over  the  posterior  surfaces  of  the  soft  palate  as  far  as  the  raphe. 

The  action  of  the  fifth  and  last  muscle,  the  az3'gos  uvulae,  it  is 
perhaps  not  absolutely  necessary  to  consider, — its  influence,  for 
separation  of  the  wound,  being  very  trifling. 

Section  of  the  levator  palati  is  thought  to  be  easiest  of  perform- 
ance after  the  manner  suggested  by  Mr.  Pollock.  This  gentleman 
first  puts  the  flap  on  stretch,  and  then,  with  a  double-edged  knife, 
makes  an  incision  through  the  soft  palate  just  on  the  inner  side  of 
the  bamular  process.  The  handle  is  now  alternately  elevated  and 
depressed,  a  sweeping  cut  being  made  along  the  posterior  surface  of 
the  soft  palate. 

The  other  anatomical  elements  of  the  soft  palate  are  glandular 
structures,  vessels,  nerves,  etc.,  all  associated,  more  or  less  inti- 
mately, by  connective  tissues;  but  these  need  not  be  particularly 
referred  to,  as  one  could  not  well  dissect  out  the  muscles  without 
necessarily  familiarizing  himself  with  them.  Thus,  then,  we  under- 
stand the  surgical  anatomy  proper  of  the  parts, — the  anatomy  as  it 
has  relation  to  cleft  palate. 

The  operation  of  staphyloraphy  was  first  practiced  by  a  dentist 
of  Paris, — La  Monier.  It  has  for  its  object  the  bringing  together  of 
the  separated  portions  of  a  cleft  soft  palate  and  the  retention  of  the 
parts  in  apposition  until  nature  shall  unite  thom. 

The  operation  consists  of  four  dififerent  stages,  with  an  object  to 
be  attained  by  each  stage  : 

1st.  The  paring  of  the  edges  of  the  cleft. 

2d.  The  introduction  of  ligatures. 

3d.  The  bringing  together  of  the  freshened  edges,  and  fixing  the 
ligatures. 

4th.  The  relief  of  any  tension  on  the  ligatures  that  may  attend 
the  approximation  of  the  parts. 

These  are  the  steps  or  stages,  and  to  accomplish  them  various 
means  and  instruments  have  been  devised, — some  good,  some  bad, 
some  indifferent.     The  reader  curious  in  such  matters  will  find  an 


PALATINE  DEFECTS  AND    THEIR    TREATMENT    1019 

admirable  and  most  instructive  chapter  on  the  subject  in  the  Sj'Stera 
of  Surgery,  published  in  1851,  by  Professor  H.  H.  Smith,  of  the 
University  of  Pennsylvania.  In  the  chapter  therein  devoted  to 
stiiphyloraphy  is  given  a  synopsis  of  the  operations  as  practiced 
by  surgeons  whose  names  have  been  and  are  particularly  asso- 
ciated with  the  subject. 

An  epitome  may  be  made  of  this  chapter  by  noticing  that  the 
operation  first  suggested  by  La  Monier,  in  1764,  was  revived  by 
Graefe,  of  Berlin,  in  1817,  but  first  methodized  and  published,  with 
the  rules  for  its  performance,  by  Roux,  of  Paris,  about  1819.  In 
1820  a  nearly  similar  operation  was  performed  by  Dr.  John  C. 
Warren,  of  Boston,  he  being  at  that  time  ignorant  of  the  views  or 
operations  of  other  surgeons.  In  many  respects  the  steps  proposed 
by  Drs.  Warren  and  Roux  correspond,  though  the  means  suggested 
by  Dr.  Warren  are  simplest,  the  operation  of  the  latter  being,  how- 
ever, generally  regarded  as  the  basis  of  the  various  modifications 
that  have  since  perfected  the  proceeding. 

The  instruments  prepared  by  Roux  for  performing  the  operation 
are  alluded  to  as. being  sufficiently  complicated.  To  execute  the 
manipulations,  he  seated  his  patient  before  a  strong  light,  with  his 
head  thrown  back  and  supported  against  the  chest  of  an  assistant, 
the  mouth  being  kept  wide  open  by  means  of  a  cork  placed  be- 
neath the  molar  teeth.  The  surgeon  then  placed  himself  in  front, 
and,  with  forceps  held  in  the  left  hand,  seized  the  right  lip  of  the 
fissure.  With  his  right  hand  armed  with  a  needle-holder,  he  next 
introduced  the  point  of  the  needle  from  before  backward  behind  the 
uvula,  in  order  to  traverse  the  flap  from  behind  forward,  at  three  or 
four  lines  from  the  free  edge  of  the  fissure.  The  needle,  being  thrust 
in  as  far  as  its  head,  was  then  freed  from  the  needle-holder,  and 
seized  at  its  point  by  forceps,  which  drew  it  and  the  ligature  through 
into  the  mouth.  After  permitting  a  few  minutes  of  rest  to  the 
patient,  the  same  mauceuvre  was  practiced  on  the  left  side  of  the 
fissure  with  the  other  needle  of  the  same  ligature,  the  two  ends  of 
which  were  thus  brought  out  into  the  mouth.  In  passing  these 
ligatures,  M.  Roux  commenced  with  the  lowest,  next  passed  to  the 
highest,  and  ended  with  the  middle. 

The  next  step  in  the  operation  of  Roux  was  to  freshen  the  edges 
of  the  fissure.  This  he  accomplished  by  seizing  the  margins,  as 
before,  with  his  forceps,  and  paring  from  behind  forward. 

To  tie  the  ligatures,  this  surgeon  commenced  by  knotting  the 
middle  one  with  the  fingers,  and,  after  making  a  simple  knot,  con- 


1020  OBAL  DISEASES  AND  SURGERY. 

fiding  it  to  an  assistant,  who  held  it  with  an  instrument  termed  by 
the  French  a  serre-noeud  (knot-tier)  ;  he  then  passed  on  to  the 
second  ligature,  and  from  that  to  the  first,  drawing  them  tighter 
than  was  necessary  to  approximate  the  edges  of  the  wound,  in  order 
to  prevent  any  separation.  Eating,  drinking,  and  speaking  were 
interdicted  the  patient  for  from  two  to  three  days,  the  ligature 
being  removed  on  the  third  or  fourth  day,  excepting  the  lowest 
one,  which  was  allowed  to  remain  twenty-four  hours  longer  than 
the  other. 

Dr.  John  C.  Warren  performed  the  operation  as  follows.  The 
patient  being  well  supported  and  secured,  a  piece  of  wood,  an  inch 
wide,  a  little  curved  at  the  end,  and  with  a  handle  to  be  held  by  an 
assistant,  was  placed  on  the  molar  teeth  of  one  side  to  keep  the 
mouth  open.  A  sharp-pointed  curved  bistoury  was  then  thrust 
through  the  top  of  the  palate,  above  the  angles  of  the  fissure,  and 
carried  down  on  one  edge  of  the  cleft  to  its  extremity,  and  the  same 
was  done  on  the  opposite  side,  so  as  to  cut  out  a  piece  in  the  form 
of  a  letter  Y,  including  about  a  line  from  each  edge.  Next  a  hook, 
or  curved  needle,  fastened  in  a  handle,  with  an  eye  on  its  extremity, 
and  a  movable  point,  armed  with  a  triple  thread  of  strong  silk,  was 
passed  doubled  into  the  mouth  through  the  fi.ssure  behind  the  palate, 
and  the  latter  pierced  by  it  one-third  the  length  of  the  fissure  from 
the  upper  angle  of  the  wound,  so  as  to  include  about  three  lines  of 
the  edge  of  the  soft  palate.  The  eye,  with  the  ligature,  being  seen, 
was  seized  with  a  common  hook  and  drawn  out.  The  eyed  hook 
was  then  drawn  back,  turned  behind  the  palate,  and  the  other  edge 
transfixed  in  a  similar  manner.  A  second  and  a  third  stitch  were 
now  passed  in  a  similar  manner,  the  third  being  as  near  as  possible 
to  the  lower  end  of  the  fissure.  Then,  seizing  the  upper  ligature 
with  the  finger,  the  knot  was  tied  without  using  a  serre-nceud,  and 
placed  on  one  side  of  the  wound  in  order  to  prevent  its  pressing  on 
the  fissure,  the  other  being  tied  in  like  manner,  and  the  fissure  closed. 

After  the  first  operation  of  Dr.  Warren,  Dr.  A.  H.  Stevens,  of  New 
York,  in  September,  1826  (see  North  American  Medical  Journal, 
vol.  iii.  p.  233),  operated  successfully,  by  first  inserting  the  ligatures 
and  then  paring  the  edges. 

In  1827,  Dr.  Mettauer,  of  Yirginia,  operated  for  staphyloraphy, 
and  in  1837  published  an  excellent  essay.  Dr.  M.  employed  leaden 
ligatures.  (See  American  Journal  of  Ihe  3Iedical  Sciences,  vol.  xxi. 
p.  309.) 

Allusions  are  made  in  this  chapter  to  other  operators  and  opera- 


i 


PALATINE  DEFECTS  AND    THEIR    TREATMENT.    1021 

tions  ;  but,  as  they  are  all  only  modifications  of  the  methods  of  Roux 
and  Warren,  it  is  not  necessary  to  refer  to  them. 

Several  years  back  I  had  in  my  possession  a  monograph  on  the 
subject  of  staphyloraphy  from  the  pen  of  the  late  Prof.  Miitter.  I 
regret  that  I  cannot  now  lay  my  hands  upon  it.  Dr.  Miilter  was 
much  interested  in  the  operation,  and  his  pamphlet  abounded  in  cases 
illustrating  his  success  in  this  direction. 

To  Mr.  Fergusson,  of  England,  however,  more  than  to  any  other 
man,  perhaps,  are  we  indebted  for  a  scientific  appreciation  of  the 
requirements  in  staphyloraphy.  The  cutting  and  sewing  parts  of 
the  operation  are  simple  mechanical  manipulations,  which  are  of 
consequence  only  as  they  tax  the  ingenuity  of  the  surgeon.  The 
proper  surgical  understanding  of  the  subject  consists,  as  we  are 
prepared  to  see,  in  a  just  acquaintance  with  the  muscular  relations 
of  the  parts.  These  relations  we  have  already  studied.  To  Mr. 
Fergusson  belongs  the  credit  of  first  making  these  demonstrations. 
It  is  very  true  that  before  his  time  incisions  in  the  soft  parts  had 
been  advised.  Roux,  Diefifenbach,  Mettauer,  Listen,  and  Warren 
all  practiced  them  where  difficulty  was  met  with  in  approximating 
the  fissure  ;  but  the  incision  practiced  by  them,  as  remarked  by  Mr. 
Fergusson,  seems  to  have  been  without  reference  to  the  anatomy  of 
the  parts,  and,  as  a  consequence,  rendered  success  somewhat  a  matter 
of  accident.  The  operation  of  Mr.  Fergusson,  so  far  as  the  paring 
and  bringing  of  the  fissured  parts  together  are  concerned,  is  much 
the  same  as  that  practiced  by  Dr.  Warren.  He  pares  the  cleft  before 
inserting  his  sutures,  and  his  knots  are  made  about  as  Dr.  Warren's. 

In  looking  over  the  history  of  staphyloraphy,  the  reader  will  be 
struck  with  the  likeness  in  complaints,  the  three  principal  of  which 
seem  to  be  the  difficulty  in  tying  the  ligatures,  the  great  tendency  of 
the  ligatures  to  slough  out  after  they  are  once  nicely  secured,  and 
the  concealment  of  the  parts  during  operation,  both  because  of  defi- 
ciency in  light  and  the  accumulation  of  the  viscid  muco-saliva  which 
in  mouths  thus  affected -is  secreted  in  such  abundance. 

Now,  in  the  direction  of  operations  in  and  about  the  oral  cavity, 
I  have  had  that  experience  and  that  practice  which  will,  perhaps, 
justify  me  in  asserting  that  there  is  an  easier  and  more  philosophical 
mode  of  performing  the  operation  of  staphyloraphy  than  has  yet 
been  practiced.  To  sit  in  front  of  a  patient  and  operate  in  the  mouth 
is  most  unhandy.  The  operator  is  in  his  own  light ;  besides,  it 
is  certainly  much  more  difficult  to  operate  sitting  than  standing: 
motion  is  cramped,  freedom  is  interfered  with.     To  operate  on  the 


1022  ORAL  DISEASES  AND  SURGERY. 

mouth  of  a  patient,  when  the  surgeon  is  seated  in  front,  venders 
necessary  an  assistant,  whose  ofiBce  it  is  to  manage  the  head.  This 
has  a  twofold  objection.  In  the  first  place,  the  assistant  cannot 
follow  in  all  those  little  changes  wnich  are  so  necessary  to  success. 
He  does  not  see  quickly  the  shiftings  and  turnings  which  so  assist 
in  the  manipulations.  Again,  one  is  more  naturall}'  ambidextral 
when  the  arms  are  supported  than  when  they  are  unsupported.  In 
operating  sitting  in  front  of  a  patient,  the  surgeon  must  work  at 
arm's  length ;  he  has  nothing  to  steady  him, — no  guard  which  shall 
enable  him  to  shield  himself  against  any  sudden  awkward  move- 
ment on  the  part  either  of  the  assistant  or  the  patient. 

To  make  a  knot  in  a  deep  canal,  such  as  the  mouth  or  the  vagina, 
is  not  easy.  To  fix  a  ligature  by  compressing  something  upon  it  is 
very  simple.  Silk  acts  as  an  irritant  to  human  tissue,-^silver  or 
lead  does  not;  therefore,  where  it  is  desirable  to  retain  a  ligature 
for  several  days  or  weeks,  without  irritation,  metal  is  best  adapted. 

Instruments  perfectly  suited  to  an  operation  simplify  it  greatly. 

Predicating  an  operation  on  these  self-evident  truths,  I  commend 
the  following  as  the  best  and  easiest  mode  of  manipulating,  believing 
that  where  once  practiced  it  will  take  precedence  of  all  other  modes. 

The  instruments  required  are  those  belonging  to  the  ordinary 
vesico-vaginal  case, — the  long-handled  knife,  needles,  and  needle- 
carrier,  shot-carrier  and  compressor,  tenaculum,  cutting  forceps, 
silver  or  lead  wire,  the  perforated  flat  shot  of  McLean,  and  mop- 
sticks.  Better  instruments  than  the.se  for  the  operation  of  sta- 
phyloraphy  will  not,  I  think,  soon  be  devised.  The  instruments 
arranged  on  a  tray  in  the  order  in  which  they  are  to  be  used,  the 
patient,  having  bad  the  steps  of  the  operation  explained  to  him, — for 
much  is  expected  from  him, — is  seated  on  a  chair  having  a  movable 
bead-rest:  it  is  well  if  this  rest  moves  in  a  ball-and-socket  joint;  at 
any  rate,  it  must  be  movable  backward  and  forward.  The  ordinary 
dental  chair  answers  the  purpose  admirably.  When  the  head  is 
placed  on  this  rest,  the  mouth  will  be  found  to  look  directly  upward. 
The  surgeon  now  takes  his  position  back  of  the  patient,  standing  on 
a  footstool  of  such  height  that  his  breast  shall  be  brought  on  a  level 
with  the  head  of  the  patient.  If  the  reader  is  disposed,  he  can  thus 
seat  a  friend,  and,  taking  a  position  back  of  him,  by  leaning  over  his 
head  he  will  find  that  when  the  mouth  is  opened  he  not  only  has  a 
most  perfect  view  of  a  thoroughly  lighted  cavity,  but  by  leaning 
against  him,  and  passing  his  arms  around  the  head  so  as  to  bring 
the  hands  to  the  mouth,  he  will  perceive  that,  besides  having  his 


PALATINE  DEFECTS  AND    THEIR    TREATMENT.   1023 

own  arms  so  steadied  as  to  allow  of  the  easiest  manipulation,  be 
bas  the  movements  of  the  patient  completely  under  his  control. 

Now,  this  relative  position  of  the  surgeon  to  his  patient  gives  him 
not  only  the  advantages  enumerated,  but  be  is  out  of  the  way  of  all 
expectorative  efforts.  If  saliva  and  blood  should  accumulate  about 
the  parts  at  which  be  is  working,  he  can  and  will,  almost  uncon- 
sciously, and  certainly  without  effort,  so  turn  the  bead  that,  while 
be  does  not  at  all  interfere  with  his  own  manipulations,  be  throws 
the  fluid  into  some  more  convenient  part  of  the  mouth.  This  I 
know  can  be  done  so  readily  that  each  step  of  the  operation  may  be 
accomplished  without  the  annoyance  and  delay  experienced  in  using 
the  mop.  Certainly,  a  patient  so  held  cannot  make  any  movement 
too  quickly  or  too  unexpectedly  for  the  surgeon.  True,  he  might  be 
so  obstreperous  that  the  operation  could  not  be  accomplished  ;  but 
be  could  not  make  any  change  which  the  knife  of  the  operator  would 
not  intuitively  follow,  and  therefore  any  accidental  barm  could  not 
be  done. 

Patient  and  surgeon  being  thus  in  position,  the  tenaculum  is  taken 
up  and  carried  through  the  very  point  of  the  cleft  pendulum.  See 
Fig.  2,  Plate  XVI.  The  part  is  then  put  on  stretch,  and  a,  paring 
(as  shown  in  the  diagram)  of  about  a  line  is  taken  from  the  whole  of 
that  side,  cutting  from  behind  forward.  The  manipulation  is  repeated 
on  the  opposite  side.  The  first  stage  completed,  very  dilute  compound 
tincture  of  capsicum,  3i'j  to  sxvj  of  water,  or  water  medicated  with 
cologne,  is  given  the  patient,  with  which  to  gargle  and  wash  the 
mouth.  These  I  find  to  cleanse  the  mouth  admirably,  besides  acting 
as  healthy  stimulants. 

The  bleeding  arrested  and  the  patient  a  little  recovered,  the  sec- 
ond step  of  passing  the  ligature  may  be  attempted.  Take  up  one 
of  the  curved  needles,  and,  threading  it  with  the  silver  wire,  fix  it 
in  the  needle-carrier.  Passing  now  the  instrument  into  the  mouth, 
thrust  the  needle  through  one  side  of  the  cleft,  about  three  lines 
from  the  margin  and  about  half  an  incb  from  the  apex  of  the  cleft 
or  bard  palate.  After  passing  it  to  the  point  at  which  it  is  held  by 
the  carrier,  it  is  to  be  caught  by  the  forceps  and  brought  through, 
the  slide  of  the  porte  being  loosened  so  as  to  permit  of  such  with- 
drawal of  the  needle  from  its  beaks.  This  accomplished,  the  needle 
is  to  be  replaced  in  the  porte  and  carried  tbrough  the  opposite  side; 
relieving  it  from  the  grasp  of  the  carrier  as  before,  the  two  cuds  are 
brought  from  the  mouth  and  their  relation  is  secured  by  one  or  two 
twists.    This  completes  the  first  ligature.    A  second  is  now  passed 


PLATE    XVI. 

A  FRONT    VIEW    OF   THE    OPERATION    OF    STAPHYLORAPIIY. 

Fig.  1. — The  operatiou  as  practiced  by  Roux.  1.  The  needle-holder  (porte- 
aiguille)  in  the  act  of  carrying  the  last  ligature  through  the  right 
side  of  the  fissure.  2.  Dressing  forceps  holding  this  margin. 
3.  The  first  ligature  as  placed,  the  ends  being  brought  out 
through  the  angles  of  the  mouth,  and  the  loop  being  loose  behind 
the  palate.  4.  The  second  ligature  as  introduced.  5.  The  third 
ligature. — After  Bernard  and  Huette. 

Fro.  2. — The  throe  ligatures,  3,  4,  5,  as  before  shown,  being  accurately  placed, 
the  surgeon  proceeds  to  freshen  tlic  edges  of  the  fissure  with  a 
probe-pointed  bistoury,  taking  care  not  to  cut  the  loops  of  the 
ligatures.  1.  Forceps  holding  the  free  end  of  the  palate.  2. 
The  bistoury  paring  off  a  strip. — After  Bernard  and  JIuette. 

Fig.  3. — Operation  of  Warren.  1.  The  knife  freshening  the  edge  of  the  fissure 
from  above  downward.  2.  The  forceps  steadying  the  margin  so 
as  to  favor  its  regular  incision. — Modified  from  Fancoad. 

Fig.  4. — The  introduction  of  the  Suture  by  means  of  Physick's  forceps  and 
a  curved  needle.  1.  Physick's  forceps  introducing  the  needle. 
2.  Dressing  forceps  seizing  its  point  at  the  moment  when  it  is 
liberated  from  the  instrument  of  Physick.  3,  4,  5.  Position  of 
the  sutures.  They  should  all  be  introduced  at  equal  distances  and 
as  nearly  parallel  as  possible. — After  Pancoast. 

Fig.  5. — The  operation  of  Staphyloplasty,  as  practiced  by  DiefTenbach.  1, 
2,  3.  The  sutures  as  tied,  and  closing  the  fissure.  4,  5.  'J'he  two 
longitudinal  incisions  made  on  each  side  of  the  soft  palate,  so  as 
to  remove  the  strain  from  the  line  of  union. — After  Bernard  and 
Huette. 


(1024) 


PALATINE  DEFECTS  AND    THEIR    TREATMENT.  1025 

half  au  inch  farther  on,  also  a  third,  or  more,  as  may  seem  needed. 
The  manipulations  required  are  of  course  the  same  as  for  the  first. 
This  completes  the  second  stage,  and  the  patient  is  allowed  to  rest 
as  before.  If  he  needs  to  wash  his  mouth,  the  surgeon  must  look 
carefully  after  his  ligatures. 

The  third  stage,  or  approximation  of  the  edges,  is  next  to  be 
accomplished.  Take  up  the  shot-carrier,  and,  slipping  through  its 
fenestra  the  twisted  ends  of  the  first  ligature  introduced,  push  the 
carrier  down  the  wires,  and  you  will  find,  as  it  approaches  the  palate, 
the  edges  of  the  cleft  approximate.  This,  1  think,  will  always  be 
found  to  be  the  case  with  the  ligature  nearest  the  hard  palate  :  the 
parts  come  together  very  easily.  You  now  slip  off  the  carrier  and 
take  up  one  of  the  perforated  shot ;  put  this  on  the  wires,  and  with 
the  carrier  force  it  down  to  the  palate.  Holding  it  now  in  place, 
which  is  done  simph^  by  laying  the  wires  against  the  carrier  and 
shifting  your  finger  over  it,  take  up  with  the  right  hand  the  forceps, 
and  compress  the  shot  tightly  upon  the  wires.  The  parts  up  to  this 
ligature  will  now  be  found  nicely  approximated  and  fixed.  This 
completed,  repeat  the  operation  on  the  second  ligature.  But  this 
will  be  found,  perhaps,  impossible,  without  greatly  overstraining  the 
parts  and  risking  the  tearing  out  of  the  wire. 

•If  this  is  the  case,  you  at  once  desist  from  the  attempt,  and  make 
the  section  as  described  of  the  tensor  palati  muscles  on  either  side. 
Now  most  likely  the  parts  will  come  together  comfortably:  if  so, 
fix  them  with  the  shot  as  before  ;  if,  however,  an  approximation  has 
not  yet  been  secured,  nick  the  anterior  half-arch  ;  and  if  this  does 
not  suffice,  cut  the  posterior  and  the  levator  palati :  the  ligature  may 
then  be  fixed,  as  well  as  those  still  farther  back.  Each  shot  firmly 
compressed,  the  wires  are  to  be  cut  off  as  closely  as  possible.  Thus 
the  third  and  fourth  steps  of  the  operation  are  completed,  and 
nothing  remains  but  to  enjoin  on  the  patient  the  most  perfect  rest. 
Herein  lies  half  the  secret  of  success  :  the  patient  should  scarcely 
move  for  two  or  three  days  ;  certainly  he  should  not  be  permitted 
any  food  that  would  demand  for  its  comminution  the  slightest  effort 
of  mastication.  He  should  be  directed  to  allow  the  liquids  he  may 
take  to  trickle  down  his  throat,  rather  than  to  attempt  to  swallow 
them.  These  restrictions  need  not,  however,  be  made  quite  so  strict 
if  in  the  operation  myotomy  of  the  half-arches  has  been  performed. 

In  the  old  mode  of  performing  the  operation,  it  was  found  neces- 
sary after  the  first  day  or  two  to  remove  the  ligatures,  because 

64 


1026  ORAL  DISEASES  AND  SVBGERY. 

of  their  tendency  to  slough  out :  the  use  of  silver  wire  obviates  this 
necessity  to  a  great  extent,  as  the  metal  seems  to  provoke  no  inflam- 
mation. These  ligatures  may  therefore,  if  they  seem  useful,  be  allowed 
to  remain  from  one  to  three  weeks.  This  non-irritating  quality  of 
metal  ligatures  is  so  marked  that  I  have  seen  them,  when  applied 
on  varicose  veins,  as  firmly  fixed  after  four  months  as  the  first  day 
they  were  put  on.  This  is  the  feature  which  adapts  such  ligature- 
material  so  admirably  for  staphyloraphy. 

The  wounds  made  in  dividing  the  muscles  may  be  left  to  nature. 
If  the  patient  is  in  condition  for  the  principal  operations,  he  is  in  a 
condition  which  does  away  with  any  necessity  for  care  in  trifling 
flesh-wounds  ;  if,  however,  any  trouble  should  arise  in  such  a  direc- 
tion, the  practice  would  be  that  which  would  apply  to  similar  wounds, 
however  made. 

It  is  seen  that  the  manipulations  here  suggested  for  the  cure  of 
cleft  palate  are  precisely  the  same  as  those  practiced  in  vesico-vaginal 
fistula,  and  that  the  instruments  adapted  to  the  one  are  exactly  suited 
for  the  other. 

The  position  in  operating  is,  I  think,  a  new  suggestion,  and  is 
founded  on  a  somewhat  extended  experience  in  manipulating  upon 
and  about  the  mouth.  To  the  author  it  seems  the  proper  one  for 
performing  the  operation  easily  and  comfortably ;  the  advantages 
which  it  possesses  over  the  old  mode  of  sitting  down  in  front  of  the 
patient  are  so  easily  studied  upon  the  person  of  any  one,  that  I  trust 
the  suggestion  will  receive  the  attention  it  will  be  found  to  merit.* 

From  this  consideration  of  cleft  palate  proper,  we  may  pass  to  the 
study  of  other  defects  of  the  parts. 

Holes  in  the  Palate. — Breaks  in  the  continuity  of  the  palate 
may  be  treated  in  two  ways :  either  by  an  operation  strictly  sur- 
gical, as  reference  may  be  had  to  the  use  of  the  knife;  or,  by  means 
which  might  be  denominated  surgico-mechanical.  If  the  knife  is  to 
be  exclusively  used,  we  have  simply  to  pare  the  edges  of  the  break, 
and  then  get  the  parts  in  apposition  as  best  we  can.  Herein  consists, 
however,  the  difficulty  of  such  operations ;  and  the  tact  and  knowledge 
of  the  surgeon  will  prove  his  best  guides.  If  the  breaks  are  in  the 
soft  palate,  any  resistance  that  may  be  met  with  is  to  be  overcome 


*  These  manipulations  were  first  practiced  and  described  in  papers  published 
by  the  author  in  the  Medical  and  Surgical  Reporter  in  1861. 


PALATINE  DEFECTS  AND    THEIR    TREATMENT.    1027 

precisely  as  we  would  overcome  it  iu  stapbyloraphy :  let  the  sur- 
geon consider  what  muscle  or  muscles  oppose  him,  and  divide  them 
as  before  suggested  ;  or,  if  myotomy  seems  scarcely  necessary,  he 
can  in  all  probability  accomplish  his  purpose  by  making  lateral  slits 
through  the  mucous  membrane  alone,  or  otherwise  he  may  go  a 
little  deeper,  making  a  kind  of  semi-myotomy. 

If  the  break  be  small,  one  ligature  will  perhaps  be  all  that  is 
necessary  to  secure  the  approximation  of  the  pared  edges ;  this  suture 
is  to  be  made  and  fixed  precisely  as  in  the  previous  operation.  If 
more  than  one  suture  seems  indicated,  of  course  more  are  to  be 
employed. 

Defects  in  the  hard  palate  are  also  amenable  to  surgical  skill : 
they  may  be  remedied  by  the  use  of  the  knife  and  stimulating  local 
applications,  or,  if  these  fail,  an  artificial  palate,  properly  constructed, 
will  so  admirably  supply  the  deficiency  that  the  patient  is  rendered 
almost  as  well  off  as  his  fellows. 

Using  the  knife  alone,  most  successful  results  are  frequently  at- 
tained by  first  paring  the  edges  of  the  break  and  afterward  dissect- 
ing the  parts  freely  from  the  bone.  This  mode  of  operating  is 
suited  to  such  hard  palates  as  have  a  thick,  soft,  mucous  membrane. 
By  such  a  mode  of  operating,  and  with  such  character  of  mucous 
membrane,  quite  wide  chasms  may  be  easily  spanned. 

With  such  mucous  membrane,  plastic  operations  will  be  found  to 
answer  very  well.  It  is  quite  easy  to  get  a  flap  without  disturbing 
the  periosteum,  and  such  a  flap  may  be  twisted  on  its  pedicle  with- 
out any  special  interference  with  its  function.  The  pedicle,  however, 
should  be  as  wide  as  possible,  remembering  that  the  circulation  per- 
tains to  the  basement  membrane  alone.  An  objection,  however,  to 
such  operations  in  the  mouth  is  the  difficulty  that  attends  the  fixing 
of  the  flap  in  its  new  place. 

The  next  mode  of  relieving  these  defects  that  may  be  alluded  to 
is  that  originally  suggested  by  Dieffenbach.  This  surgeon  commends 
the  penciling  of  the  edges  of  the  break  with  tincture  of  cantharides, 
hoping  thereby  to  excite  granulation  to  an  extent  that  shall  fill  up 
the  cleft. 

Now,  while  this  does  very  well  for  small  holes,  it  seldom  succeeds 
with  the  larger.  The  granulations,  having  nothing  to  support  them, 
break  down  before  connecting  in  the  middle. 

This  defect  in  the  treatment  can  be  remedied,  and  success  almost 
warranted,  by  the  following  modification:  make  a  simple  obturator 


1028  ORAL  DISEASES  AND  SURGERY. 

or  artificial  palate;  the  mode  of  doing  which  is  described  in  the 
following  chapter.  After  fitting  this  so  as  to  cover  accurately  every 
portion  of  the  hard  palate,  it  may  be  removed,  and  the  cleft  pared  ; 
next  touch  the  parts  with  cantharides  or  tincture  of  iodine, — the 
latter  is  to  be  preferred.  The  plate  is  now  to  be  replaced,  and  will 
be  found  to  act  most  completely  as  a  support  to  the  granulations 
which  will  be  formed.  The  process  of  freshening  the  edges  is,  of 
course,  to  be  frequently  repeated  ;  but  after  the  first  paring  the  cuts 
may  be  made  from  the  circle  on,  and  not  around,  the  cavity. 

XJranoplastt. — To  Dr.  J.  Mason  Warren  seems  justly  due  the 
credit  of  the  conception  of  this  operation.  His  plan  of  manipulation 
was  as  follows.  Incisions  were  first  made  on  either  side  of  the 
cleft  down  to  the  submucous  cellular  tissue,  being  midway  between 
the  borders  of  the  break  and  the  alveolar  processes,  these  incisions 
extending  back  to  the  extent  of  the  break.  Next,  using  a  double- 
edged  knife,  these  flaps  were  dissected  toward  the  cleft,  and,  falling, 
were  united  in  the  middle  line.  Another  plan  practiced  by  this 
surgeon  consisted  in  dissecting  the  mucous  membrane  from  the 
edges  of  the  cleft  toward  the  alveolar  processes,  and,  as  they  were 
thus  nrade  loose  and  pendulous,  uniting  them  along  the  centre  line. 

A  modification  by  Langenbeck  on  the  operali.on  of  Warren  consists 
i»  including  in  the  dissection  the  periosteum,  thus  taking  advantage 
of  its  osteogenetic  qualities  to  secure  the  filling  of  the  break  by  a 
deposit  of  bone. 

The  use  of  a  gag  to  keep  the  jaws  separated,  both  in  the  opera- 
tion of  staphyloraphy  and  in  that  of  uranoplasty,  will  be  found  to  add 
to  convenience  in  the  operation.  The  instrument  of  Kolbe,  shown  on 
page  207,  the  author  occasionally  uses  with  much  satisfaction.  A 
means,  however,  more  commonly  employed  is  known  as  Whitehead's 
Gag  and  Tongue-Depressor ;  this  consists  of  two  curved  bars,  one 
supporting  either  jaw,  kept  separated  by  a  ratchet  lever ;  to  the  lower 
bar  being  attached  the  tongue-holder.  A  modification  of  this  gag 
(or,  more  properly  speaking,  of  the  Smith  gag,  which  is  much  like  it), 
made  by  Dr.  Louis  Elsberg,*  of  New  York,  is  preferred  by  many. 

Another  form  of  gag  is  a  very  simple,  but  yet  quite  effective, 
apparatus  devised  by  Dr.  Goodwillie,  shown  in  Fig.  332 :  this  consists 
of  two  arms  covered  with  elastic  rubber,  with  a  central  screw  which 

*  A  sponge-holder  of  most  convenient  form  and  construction,  and  of  great 
service  in  operations  about  the  mouth,  is  known  as  Elsberg's  sponge- forceps. 


PALATINE  DEFECTS  AND    THEIR   TREATMENT. 


1029 


increases  or  diminishes  the  length  of  the  piece  as  required, 
of  this  class  require,  however,  to  be  held  in  by  the  finder 
assistant. 

Still  another  form  of  this  instrument  is  one  devised 
by  John  Wood,  of  King's  College  Hospital,  and 
which  is  used  exclusively  by  Sir  Wm.  Fergusson  in 
his  operations  about  the  mouth :  this  consists  of  a 
double  bar,  having  rests  for  the  support  of  the  teeth, 
and  which  are  separated  on  a  principle  precisely  the 
same  as  that  employed  with  the  bivalve  speculum. 


Gags 
of  an 


Fig.  3.32. 


The  next  class  of  palatine  defects  which  claim  our  attention  are 
such  as  require  for  their  relief  mechanical  treatment.  This  brings 
us  to  the  subject  of  the  obturator, — an  instrument  whose  style,  form, 
and  manufacture  are  of  the  same  interest  to  the  surgeon  as  are  those 
of  the  pessary  to  the  obstetrician. 


CHAPTER    L. 


OBTURATORS. 


The  instniment,  or  plate,  called  an  obturator,  gets  its  name  from 
the  Latin  verb  ohturo,  and  signifies  a  something  that  shall  close 
or  stop  up  an  entrance  or  break.  Thus,  after  the  operation  of  tre- 
phining, it  is  not  uncommon  to  shield  the  exposed  brain  against  risk 
of  accident  by  fitting  a  silver  plate  over  the  site  of  the  removed  bone ; 
and  this  shield  is,  to  all  intents  and  purposes,  an  obturator:  it  closes 
the  break  in  the  continuity. 

In  the  treatment  of  palatine  defects,  obturators  may  be  employed 
with  the  greatest  success;  the  range  of  their  application  is  really 
wonderful.  I  have  seen  one  case,  at  least,  where  the  whole  side  of 
a  face  has  been  so  completely  restored  through  such  instrumentality, 
that  a  passing  observer  would  scarcely,  I  think,  have  remarked  any- 
thing amiss  with  the  wearer. 

In  the  consideration  of  the  more  strictly  surgical  treatment  of  pala- 
tine defects,  we  studied  the  operations  which  suggested  themselves 
as  being  the  most  effective  and  promising.  It  is  not,  however,  as 
will  be  found,  every  patient  who  is  willing  to  submit  to  an  operation  ; 
and  it  is  not,  on  the  other  hand,  as  we  are  prepared  to  understand, 
every  case  that  is  fit  to  be  operated  upon.  To  leave  either  class  of 
persons  to  their  fate  would  be  as  cruel  as  it  would  be  unnecessary ; 
it  is  here,  therefore,  we  may  so  happily  resort  to  the  means  known 
as  the  surgico-mechanical. 

As  obturators  are  to  fulfill  various  indications,  so,  of  course,  do 
they  vary  in  form,  style,  and  method  of  manufacture.  The  simplest 
obturator  is  one  made  to  cover  a  break,  more  or  less  extensive, 
in  the  hard  palate  proper, — that  is,  a  break  which  does  not  impli- 
cate either  the  alveolar  borders  or  the  soft  palate.  Such  an  obtu- 
rator holds  the  same  relative  position  to  obturators  in  general  that 
the  Physick-Dessault  apparatus  holds  to  all  apparatus  for  thigh- 
fractures  ;  both  may  be  termed  principals,  and  all  variations  are 
but  modifications  of  these  principals:  thus,  if  we  appreciate  the 
(1030) 


OBTUBATORS.  1031 

style,  indications  met,  and  mode  of  manufacture  of  a  simple  obturator, 
we  sliall  understand  fully  the  genius  of  the  instrument,  and  be 
enabled  so  to  appreciate  the  mechanism  of  the  piece  that  we  will  be 
prepared  to  diminish  or  enlarge  its  capacity  pro  re  nata. 

A  patient  presents  himself,  let  us  suppose,  suffering  under  a  de- 
ficiency in  the  hard  palate.  We  examine  the  case,  and  find  the 
walls  of  the  break  so  heavily  and  solidly  indurated  that  we  perceive 
at  once  that  any  attempt  to  pare  and  bring  the  pans  together  would 
be  futile.  Palato-plasty  at  once,  and  naturally,  suggests  itself,  but 
observation  of  the  surrounding  parts  convinces  us  that  the  risks  are 
too  great  for  the  good  promised.  Such  is  a  case  that  not  unfre- 
quently  offers  itself  to  the  surgeon's  judgment.  Dieffenbach,  whose 
name  is  so  honorably  associated  with  oral  surgery,  evidently  found 
himself  much  embarrassed  with  just  such  cases, — cases  which  I 
would  here  present  as  the  easiest  of  remedy  by  use  of  the  obturator. 
It  was  Dieffenbach,  it  will  be  remembered,  who  suggested  the  stud 
of  india-rubber.  Two  pieces  of  rubber  the  thickness  of  pasteboard 
were  cut,  being  somewhat  larger  than  the  opening  to  be  closed,  and 
between  these  was  placed  a  small  round  piece;  the  whole  was  then 
securely  fastened  together  by  means  of  waxed  thread  ;  one  of  these 
pieces  was  intended  to  rest  on  the  posterior  and  the  other  on  the 
anterior  surface  of  the  opening ;  the  small  middle  piece  w^as  for  the 
intermediate  space. 

A  moment's  reflection  will  exhibit  the  inconveniences  as  well 
as  the  more  striking  faults  of  such  an  appliance.  The  rubber,  unless 
it  were  vulcanized  (and,  to  be  so  applied,  it  could  not  be  vulcanized), 
would  soon  become  very  offensive.  It  would  act  as  a  continual 
source  of  irritation,  and  particularly  so  far  as  the  posterior  base  of 
the  cleft  is  concerned.  The  centre  piece,  which,  to  hold  the  parts 
with  any  degree  of  steadiness,  would  have  to  fit  the  opening  with 
some  degree  of  accuracy,  would,  because  of  the  presence  of  moisture 
and  heat,  soon  expand,  thus  enlarging  the  canal.  It  would  be  very 
inconvenient  to  remove  for  the  purpose  of  cleansing,  which  cleans- 
ing it  would  certainly  demand  daily. 

A  case  amply  illustrative  of  the  inefficiency  of  this  mode  of 
treating  palatine  defects,  and,  indeed,  of  the  absolute  harm  resulting 
from  it,  is  recorded  by  Dr.  J.  H.  McQuillen,  in  the  Dental  Cosmos. 
The  patient,  who  had  an  opening  in  the  palate,  the  result  of  syphilis, 
was  treated  by  Dr.  Daniel  Neall,  who  employed,  in  the  first  in- 
stance, india-rubber  as  a  substance  from  which  to  construct  an  obtu- 
rator.   This  w\as  cut  somewhat  in  a  button  shape,  being  large  above 


1032  ORAL  DISEASES  AND  SURGERY. 

and  below,  and  contracted  in  the  centre,  thns  constituting  an  ap- 
paratus which  was  retained  in  position  by  resting  on  the  floor  of 
the  nares,  surrounding  the  orifice.  After  this  had  been  worn  a  week 
or  two,  the  patient  returned,  when  it  was  found  quite  loose  and  the 
orifice  somewhat  enlarged,  the  rubber  having  acted  as  a  source  of 
irritation  and  induced  absorption.  Another  apparatus  was  formed 
from  the  same  material,  and,  after  being  worn  a  week,  the  orifice 
was  found  much  larger  than  at  the  previous  meeting.  The  rubber 
was  also  found  considerably  affected  by  the  fluids  of  the  mouth. 
Satisfied  that  it  would  not  answer  the  purpose  intended,  this  material 
was  abandoned,  and  a  simple  obturator  of  silver  was  constructed, 
covering  the  orifice  and  roof  of  the  mouth.  This  was  found  to  fulfill 
every  indication. 

There  is  another,  a  somewhat  domestic  treatment  for  these  defects, 
which  I  may  here  allude  to.  This  consists  in  stuffing  the  break  with 
cotton  or  wool.  The  cotton  not  unfrequently  escapes  into  the  throat, 
or,  passing  into  the  nares,  it  has  sometimes  produced  ozana  by  lodg- 
ing in  the  meatus  :  quite  extensive  necrosis  of  the  turbinated  bones 
has  also  been  provoked  in  this  way.  The  practice  is  not  without 
danger. 

A  case  of  a  different  class,  yet  belonging  to  the  same  category  so 
far  as  treatment  is  concerned,  invites,  in  connection  with  the  consid- 
eration of  simple  obturators,  a  moment's  attention.  This  is  the  exist- 
ence of  a  cleft  or  break  associated  with  subacute  or  chronic  disease, — 
the  cases  to  which  we  allude  as  not  being  fit  for  operation. 

Some  time  since,  Mr.  ,  a  French  teacher  of  this  city,  had 

necrosis  of  the  palatine  arch,  the  result  of  venereal  disease;  the  se- 
questrum that  came  away  was  quite  large,  producing  a  break  in  the 
continuity  of  the  hard  ])alate  at  least  an  inch  in  diameter,  of  course 
freely  exposing  the  nares.  The  result  was,  as  might  be  anticipated, 
that  his  vocation  as  a  teacher  had  at  once  to  be  relinquished. 

I  saw  this  case,  in  consultation  with  the  attending  surgeon,  about 
a  mouth  after  the  patient  had  resigned  a  situation  which  he  held  in 
one  of  our  principal  private  schools,  and  upon  which,  up  to  this 
time,  he  had  mainly  depended  for  his  income.  The  necessities  of  the 
man  were  immediate,  and  any  operation  for  the  restoration  of  his 
speech  was  out  of  the  question.  I  had  the  happiness  of  relieving 
hi.m  of  his  trouble  so  perfectly  after  three  days,  by  the  use  of  an 
obturator,  that  every  time  we  have  since  met  he  has  laughingly 
assured  me  that  he  speaks  much  better  English  than  before  his 
accident.     It  is  certainly  true  that  he  speaks  quite  as  well. 


OBTURATOBS.  1033 

The  obturator  for  these  cases  consists  simply  of  a  metal  plate 
that  shall  fit  accurately  every  part  of  the  hard  palate,  the  regu- 
larity of  the  arch  to  be  restored  by  carrying  the  plate  over  the  cleft 
or  break.  Such  a  plate  should  fit  with  the  greatest  nicety,  and  is 
to  be  held  in  place  either  by  bands  placed  around  certain  of  the 
teeth,  or  by  means  of  atmospheric  pressure.  The  first  plan  of  fasten- 
ing the  piece  should  be  employed  when  disease  is  associated  with 
the  cleft.  The  latter  is  well  adapted  when  the  break  is  not  too  large, 
and  where  all  disease  has  long  since  passed  away.  To  make  such 
an  obturator,  first  take  an  ordinary  impression-cup,  such  as  is  em- 
ployed in  taking  casts  of  the  mouth.  This  cup  is  filled  with  bees- 
wax, softened  before  the  fire  to  the  consistency  of  dough.  Thus 
prepared,  the  operator  takes  his  position  behind  the  patient,  as  recom- 
mended in  the  operation  of  staphyloraphy.  The  cup  is  now  to  be 
introduced  carefully  into  the  mouth,  and  carried  just  so  far  back  as 
will  allow  of  the  teeth  being  included  within  the  arch  or  rim  of  the 
cup.  This  accomplished,  cup  and  wax,  in  a  body,  are  to  be  pressed 
firmly  up  into  the  roof  of  the  mouth  and  around  the  neck  of  the 
teeth  and  alveolar  border.  The  patient  holding  his  mouth  very 
wide  open,  the  mass  is  to  be  removed  even  more  carefully  than  it  was 
inserted.  This  manipulation,  if  properly  executed,  gives  us  the 
exact  impression  of  the  mouth.  The  next  step  is  to  make  a  model. 
To  do  this,  we  take  the  impression  we  have  just  obtained,  and,  sur- 
rounding it  with  a  rim  of  paper,  the  rim  to  be,  say,  one  and  a  half 
inches  in  height,  we  stir  into  water  the  common  calcined  plaster — 
sulphate  of  lime — until  we  have  a  very  thick,  creamy  paste.  This 
paste  is  poured  into  the  impression,  and  should  be  enough  to  fill 
from  the  wax,  which  lies  at  the  bottom,  up  to  the  top  of  the  rim. 
The  model  thus  made  is  not  to  be  disturbed  for  three  or  four  hours ; 
it  must  have  time  to  set. 

The  next  step  in  the  operation  is  to  remove,  from  about  the  plaster 
cast  we  have  just  made,  the  paper  and  wax.  This  is  accomplished, 
first,  by  heating  gently  the  cup  in  which  the  wax  lies,  which  permits 
of  its  easy  removal ;  and  next  by  carefully  trimming  from  about  the 
necks  of  the  teeth,  by  means  of  a  knife-blade  kept  constantly  warm, 
the  wax  which  so  closely  surrounds  and  imbeds  them ;  in  this  way 
the  wax  may  all  be  safely  taken  away.  The  paper  is,  of  course,  sim- 
ply to  be  torn  away,  and  this  is  done  before  removing  either  cup  or 
wax.  Comparing  the  face  of  the  model  thus  made  with  the  mouth 
from  which  the  impression  was  taken,  we  shall  find  we  have  its  like- 
ness to  the  minutest  particular. 


1034  ORAL  DISEASES   AND  SURGERY. 

As  the  model  contains  the  break  in  the  arch,  and  it  is  our  intention 
to  restore  this  arch  to  its  original  and  natural  contour,  so  is  it  at  this 
step  in  the  procedure  that  we  can  best  secure  our  object.  This,  I 
think,  is  most  easily  done  by  taking  a  little  ball  of  warm  wax,  and 
filling  with  it  the  hole  or  break  in  the  modiel.  The  natural  concavity 
of  the  arch  is  in  this  way  restored.  Of  course  this  is  not  at  all  diffi- 
cult, nor  is  there  any  guess-work  about  it,  as  we  have  the  inclinations 
of  all  the  surrounding  parts  to  guide  us,  and  all  we  have  to  do  is 
simply  to  model  this  wax  to  the  proper  curve. 

The  cast  is  finished  by  beveling  the  portion  which  rested  against 
the  paper;  this  beveling  to  be  so  done  that  the  greatest  diameter  of 
the  model  shall  be  its  base. 

This  completes  the  model  to  which  the  obturator  is  to  be  made. 

The  next  step  is  the  preparation  of  dies.*  These  are  to  be  made, 
one  of  zinc,  the  other  of  lead ;  and  the  process  of  getting  up  such 
casts  is  precisely  the  same  as  that  adopted  by  the  moulder. 

Procure  a  moulding-flask  or  a  circle  of  tin:  a  common  tin  cup, 
with  the  bottom  broken  o\x\,  answers  the  purpose  well  enough.  Lay 
the  model  you  have  prepared  upon  the  table,  the  palate  face  looking 
up.  Now  place  the  circle  of  tin  over  it,  and  with  some  moulder's 
sand,  very  fine,  which  you  have  previously  moistened  and  tempered, 
cover  in  the  model,  packing  and  filling  the  circle  completely.  Now 
turn  the  circle  or  cup  so  that  the  base  of  the  cast  looks  up.  Next 
a  penknife-blade  or  a  small  gimlet  is  to  be  inserted  into  the  plaster, 
and  by  striking  it  several  light  taps  the  cast  will  be  loosened.  It 
is  now  to  be  lifted  from  the  sand.  Thus  we  have  a  mould  for  a 
metal  casting.  The  next  step  is  the  making  of  such  a  cast.  To  do 
this  we  have  only  to  melt,  in  any  convenient  vessel,  one  or  two 
pounds  of  common  zinc,  and  pour  it  slowly  into  the  mould.  This 
done,  let  the  whole  remain  undisturbed  until  completely  cold. 

Thus,  it  is  seen,  we  have  prepared,  with  little  or  no  labor,  a  cor- 
rect model  of  the  mouth  in  metal.  It  is  to  this  zinc  model  we  are 
to  fit  and  adapt  our  obturator.  Now,  this  latter  process  is  easy  or 
difficult,  according  as  one  goes  about  it.  One  method  is  to  take 
hammer,  files,  and  pliers,  and  cut,  file,  and  mallet,  until  the  adapta- 
tion is  secured.  Such  a  task  is  almost  as  hard  as  was  the  cleaning 
of  the  Augean  stables ;  besides,  it  is  next  to  an  impossibility  to  ac- 

*  The  model,  or  even  the  impression,  being  handed  to  the  mechanical  dentist, 
the  obturator  can  be  made,  ready  to  put  in  place,  without  further  trouble  to 
the  surgeon. 


OBTDEATOES.  1035 

complish  the  work  properly.  A  second  plan,  and  one  which  is  as 
easy,  simple,  and  interesting  as  the  other  is  difficult,  perplexing,  and 
annoying,  consists  in  making  a  counter-model  in  lead,  between  which 
and  the  model,  or  male  cast,  as  it  is  called,  the  palate  or  obturator  is 
to  be  struck  up.    This  counter-model  is  very  easily  made,  as  follows  : 

Take  the  zinc  cast  and  lay  it  upon  the  table,  with  the  face  or  pal- 
atine surface  looking  up  ;  lay  over  it  the  cup  or  circle,  precisely  as 
in  the  case  of  the  plaster  model.  Now  with  the  sand  moistened  as 
before,  fill  up  the  cup  covering  in  the  cast,  packing  the  sand  as  solidly 
as  possible.  Next,  without  disturbing  the  cup  as  it  rests  upon  the 
table,  take  a  knife  and  dig  away  the  sand  until  you  expose  the  face 
of  the  cast.  You  are  now  prepared  to  make  the  counter-model. 
Take  a  vessel  (not  the  one  in  which  you  melted  the  zinc),  and  place 
in  it  two  or  more  pounds  of  lead ;  when  melted,  pour  this  over  the 
face  of  the  zinc  cast,  filling  up  to  the  very  top  the  hole  which  you 
have  dug  out  in  the  sand.  When  the  lead  has  become  cool,  remove 
the  castings  from  the  sand,  and,  with  a  hammer,  the  two  are  easily 
knocked  apart. 

To  make  the  obturator  by  means  of  the  dies  thus  obtained,  we 
proceed  as  follows :  a  piece  of  thin  sheet-lead  is  forced  with  the  fingers 
over  the  face  of  the  zinc  cast ;  with  a  sharp  and  delicate-bladed  knife 
this  lead  is  cut  so  as  to  cover  accurately  the  hard  palate,  being  even 
festooned  so  as  to  adapt  itself  accurately  about  the  necks  of  all  the 
teeth.  This  palate  of  lead  being  thus  nicely  and  correctly  fitted  to 
the  parts,  it  is  taken  off  the  casts  and  carefully  spread.  Next  it  is 
laid  on  a  piece  of  gold  or  silver  plate,  and  the  outlines  distinctly 
marked  with  cutting  forceps ;  the  shape  of  the  arch,  as  marked  from 
the  lead,  is  then  cut  from  this  second  piece  of  metal.  The  next  step 
is  the  process  of  annealing,  or  softening  the  metal,  so  that  it  shall 
be  as  malleable  as  possible.  This  consists  in  subjecting  it  to  a  red 
beat,  which  may  be  done  in  any  convenient  manner.  The  mechan- 
ical dentist  lays  the  piece  on  charcoal,  and  throws  over  it,  by  means 
of  a  blow-pipe,  the  flame  from  his  alcohol  soldering-lamp.  This 
does  it  very  nicely. 

Next  the  metal  is  to  be  taken  up,  and  so  bent  with  pliers  as  to  fit 
the  cast  tolerably  ;  it  is  not,  however,  at  all  necessary,  in  this  proce- 
dure, to  give  one's  self  much  trouble.  Next  take  up  the  counter- 
model,  and  lay  it  carefully  over  the  zinc,— the  plate  being  between 
the  two.  With  a  hammer  the  casts  are  now  to  be  driven  together. 
In  this  step  of  the  operation  it  is  desirable  that  we  should  feel  our 
way,— that  is,  hit  the  models  a  few  slight  taps,  and  then,  taking 


1036  ORAL  DISEASES  AND  SURGERY. 

them  apart,  see  if  the  plate  is  going  as  we  want  it.  If  all  is  right, 
the  casts  may  be  driven  into  each  other  with  all  reasonable  force. 
If,  on  the  contrary,  the  plate  is  not  taking  a  proper  direction,  it  must 
be  so  inclined  by  means  of  the  pliers.  To  complete  the  finish  of  the 
plate  itself,  the  festoons,  which  are  to  embrace  the  necks  of  the  teeth, 
should  be  cleanly  cut  out  by  means  of  the  ordinary  round  file. 

Thus  we  have  an  obturator  completed.  If  we  place  it  in  the 
mouth,  we  shall  see  that  we  have  restored  the  arch,  by  our  con- 
trivance, to  its  original  condition,  at  least  so  far  as  the  purposes  of 
speech  and  mastication  are  concerned. 

Nothing  now  remains  but  to  secure  the  piece  firmly  to  its  place. 
And  this  brings  us  to  the  consideration  of  modifications  of  the 
instrument. 

If  a  patient,  for  whom  we  had  made  such  an  obturator  as  that 
the  manufacture  of  which  has  just  been  described,  had  certain  good 
sound  teeth,  we  might  proceed  to  fix  the  piece  in  the  mouth  as  fol- 
lows. Going  back  to  the  plaster  model,  we  would  fit  around  such 
teeth  as  might  seem  to  us  best  adapted  to  our  purpose,  delicate  bands 
of  metal — gold  should  always  be  preferred;  these  bands  should  fit 
the  teeth  with  great  accuracy,  and  should  be  fixed  to  their  places 
while  the  obturator  is  lying  on  the  model.  Take  next  a  particle  of 
wax,  and  stick  the  plate  and  bands  together.  Now  carefully  lift  all 
from  the  model,  and  set  in  plaster.  This  last  manipulation  is  accom- 
plished by  laying  the  piece  on  charcoal,  and  pouring  over  it,  the  wax 
alone  excepted,  the  creamy  plaster  before  alluded  to.  When  this  plas- 
ter sets,  the  wax  is  taken  away,  and  there  is  exposed  a  small  portion, 
both  of  obturator  and  bands.    These  parts  are  to  be  soldered  together. 

This  last  process  finishes  the  piece  for  the  mouth.  In  placing  it 
in  position,  we  have  only  to  slip  the  bands  over  the  teeth,  and  we 
will  find  that  it  is  held  with  all  security. 

Another  plan  of  securing  the  apparatus  to  the  mouth  is  by  means 
of  atmospheric  pressure.  To  accomplish  this,  a  cavity  is  to  be  made 
in  the  piece.  This  is  done  by  placing  on  the  plaster  model,  before 
making  the  castings  from  it,  a  piece  of  wax:  its  shape  may  repre- 
sent, in  diameter  and  thickness,  the  ordinary  half-dime.  Or  perhaps 
we  cannot  find  a  surface  on  the  arch  for  a  suction  of  such  size  and 
shape ;  if  so,  it  may  be  lessened,  or  the  shape  may  be  modified  so  as 
to  suit  any  case.  What  we  want  is  a  cavity  in  the  plate  ;  the  size 
and  location  are  not  of  great  consequence.  Such  a  piece  of  wax 
will,  of  course,  be  represented  by  zinc  in  the  casting,  and  by  a 
depression  in  the  counter-cast.     In  forcing  the  plate  between  the 


OBTURATOBS. 


1037 


dies,  the  portion  represented  bj  the  wax  is  thrown  up ;  thus,  when 
the  plate  is  in  the  mouth,  a  cavity  is  formed.  The  obturator  is  held, 
in  this  case,  by  making  an  air-pump,  as  it  were,  of  the  tongue,  and 
sucking  the  air  from  the  cavity.  I  have  seen  obturators,  thus  de- 
pendent on  atmospheric  pressure  for  fixedness,  held  so  tightly  that 
it  required  considerable  f^rce  to  effect  their  removal.  The  principle 
is  the  same  as  that  employed  for  holding  artificial  teeth  in  place. 
The  modus  operandi  will  be  perfectly  understood  at  a  glance  by 
looking  at  any  set  of  teeth  made  for  the  superior  jaw. 

Another  modification  of  the  obturator  is  that  in  which  the  piece  is 

Fig.  333. 


held  to  its  place  by  a  bulb  or  rim,  which  passes  into  the  cavity  of 
the  break.  This  adapts  the  instrument  to  such  cases  as  have  neither 
teeth  nor  site  for  suction,  where,  for  instance,  disease  has  destroyed 
the  whole  of  the  hard  palate,  leaving  alone,  as  boundaries  of  the 
cleft,  the  alveolar  processes  and  soft  palate.  Such  an  obturator  and 
the  character  of  cleft  for  which  it  is  adapted  are  happily  and  truth- 
fully exhibited  in  the  accompanying  drawings.  Fig.  333  represents 
the' mouth,  Fig.  334  the  obturator.  This  case,  and  others  which 
represent  various  modifications  of  the  apparatus,  are  from  life,  having 


1038 


ORAL  DISEASES  AND  SURGERY. 


Fig.  334. 


occurred  in  the  practice  of  prominent  dentists.  The  models  shown, 
with  an  accompanying  history  of  the  cases,  were  presented  to  the 
Pennsylvania  Association  of  Dentists,  at  a  meeting  held  by  that 
Society.* 

"  The  first  case,  as  seen  in  Fig.  334,  from  the  practice  of  Dr. 
McGrath  &  Son,  was  that  of  a  female  over  fifty  years  of  age.    In  this 

instance  the  fissure  was  confined 
to  the  hard  palate,  and  was  un- 
doubtedly the  result  of  syphilis. 
Of  the  history  of  this  case,  all  that 
could  be  obtained  was  such  as  was 
derived  from  answers  to  indirect 
questions  which  were  put  to  her. 
They  learned  that  the  defect  was 
the  result  of  a  disease  which  com- 
menced as  sore  throat  and  con- 
tinued its  ravages  for  over  three 
years  before  it  was  arrested  ;  this, 
together  with  the  appearance  of 
the  pharynx  and  uvula, — they  be- 
ing covered  with  cicatrices,  the  re- 
sult of  old  ulcers, — left  them  without  any  doubt  as  to  the  true  nature 
of  the  complaint.  The  parts  which  had  been  destroyed  during  the 
progress  of  the  disease  were  the  palate-bones  and  the  palatine  pro- 
cesses of  the  superior  maxillaries  (making  an  opening  into  the  nose 
nearly  two  inches  in  length  and  one  inch  in  breadth),  the  turbinated 
bones  (with  the  exception  of  the  middle  one  on  the  left  side,  which 
is  represented  in  the  cut  as  projecting  from  the  side  of  the  cavity), 
and  the  vomer,  producing  an  enormous  irregularly  shaped  cavity, 
extending  as  high  up  as  the  nasal  bones,  which  latter,  however, 
bore  no  traces  of  ever  having  been  affected  by  the  disease.  The 
patient,  in  order  to  prevent  the  passage  of  the  food  into  the  cavity 
during  mastication,  had  been  in  the  habit  of  filling  the  opening 
with  a  fold  of  muslin,  which  answered  the  purpose  to  a  certain  ex- 
tent ;  the  velum  was  entire ;  the  patient  had  also  lost  all  the  teeth 
of  the  upper  jaw. 

"  The  kind  of  obturator  employed  in  this  case  was  simple  and 
uncomplicated  in  its  mechanism.  Fig.  334.  A  plate  was  made  to  fit 
accurately  to  the  alveolar  ridge,  extending  about  one-eighth  of  an 


*  Report  by  Geo.  T.  Barker,  D.D.S. 


OBTURATORS.  1039 

inch  beyond  the  posterior  margin  of  the  opening ;  also  passing  in  to 
a  distance  of  nearly  an  inch,  and  fitting  as  closely  as  possible  to  the 
anterior  and  lateral  sides  of  the  cavity.  The  object  of  this  latter 
arrangement  was  to  render  the  plate  firm  in  its  position.  From  the 
posterior  margin  of  the  opening,  .and  extending  forward  about  half 
the  length  of  the  alveolar  ridge,  was  a  fold  of  mucous  membrane 
projecting  inward  and  upward,  over  this  fold  ;  that  portion  of  the 
plate  which  was  opposite  to  it  was  bent.  This,  together  with  the 
suction  obtained  by  the  plate  fitting  closely  to  the  alveolar  ridge, 
enabled  the  wearer  to  keep  it  in  its  place.  The  opening  was  then 
covered,  by  soldering  to  this  a  second  piece  of  plate,  so  fashioned 
as  to  represent  as  nearly  as  possible  the  form  of  the  lost  palate. 
The  object  in  not  extending  the  plate  into  the  cavity  on  the  poste- 
rior edge  of  the  opening  was  to  prevent  a  lodgment  for  the  nasal 
secretions,  which  by  their  accumulation  would  prove  offensive  to 
the  patient.  The  artificial  teeth  were  then  fastened  in  their  proper 
position,  and  the  apparatus  was  complete.  This  obturator  the 
patient  had  been  wearing  for  about  three  months ;  it  remained  in 
place  and  fulfilled  the  office  of  mastication  as  well  as  any  ordinary 
suction  plate  in  a  mouth  where  no  defect  of  the  palate  exists. 

"  The  second  case,  Fig.  335,  was  also  that  of  a  female,  but  the 
fissure  was  confined  to  the  soft  palate.  This,  as  in  the  former  case, 
was  the  result  of  syphilis.  The  fissure  extended  from  the  posterior 
opening  of  the  nares  through  the  velum  to  the  palate-bones,  and  was 
nearly  an  inch  in  breadth.  The  uvula  was  entirely  gone,  as  well  as 
the  lateral  half-arches,  and  along  with  them  the  palato-pharyngei 
and  constrictores  isthmi  faucium  muscles.  In  this  case  deglutition 
was  impaired  to  a  great  extent ;  the  food  would  pass  into  the  nares, 
and  the  fluids  would  also  pass  into  the  nasal  cavity  and  out  through 
their  anterior  openings.  The  disease  had  not  confined  itself  to  the 
palate,  but,  extending  to  the  nasal  organs,  had  completely  destroyed 
their  internal  structure,  as  well  as  a  portion  of  the  nasal  bone,  to 
such  an  extent  as  materially  to  change  the  external  shape  of  that 
organ.  The  obturator,  Fig.  336,  constructed  for  this  case,  was  of 
one  piece,  and  made  to  cover  the  hard  palate  completely,  extending 
from  the  central  incisors  to  the  posterior  wall  of  the  pharynx,  and 
passing  a  short  distance  beyond  the  edges  of  the  opening  on  each 
side.  The  plate  was  made  to  press  firmly  against  that  portion  of 
the  soft  palate  which  remained,  yet  not  so  firmly  as  to  be  the  cause  of 
irritation,  the  edges  of  the  plate  being  slightly  bent  downward  for 
the  same  reason ;  the  object  being  to  prevent  the  possibility  of  the 


1040 


ORAL  DISEASES  AND  SURGERY. 


soft  parts  being  drawn  above  the  palate,  which  would  afiford  a  com- 
munication with  the  nares.  The  posterior  edge  of  the  obturator  was 
bent  downward  at  a  right  angle  with  the  body  of  the  palate,  and 
curved  so  as  to  form  with  the  posterior  wall  of  the  pharynx  an  oval 
opening  sufficiently  large  to  permit  the  patient  to  breathe  freely 
through  the  nostrils.  In  the  act  of  deglutition,  the  muscles  would 
contract  and  press  against  this  portion  of  the  plate,  thereby  cutting 

Fig.  335. 


off  the  communication  with  the  nares.  To  this  plate  were  attached 
three  artificial  teeth, — two  lateral  incisors  and  one  molar, — the 
whole  being  retained  in  position  by  means  of  clasps  around  the 
teeth. 

"This  obturator  the  patient  had  been  wearing  a  little  over  two 
months,  and,  like  the  former  one,  has  proved  successful,  deglutition 
being  restored,  and  the  speech  considerably  improved." 

Dr.  T.  L.  Buckingham,  Professor  of  Chemistry  in  the  Pennsyl- 
vania College  of  Dental  Surgery,  presented  the  following  cases: 

"The  first  case,"  he  said,  "  he  had  anything  to  do  with  was  that 


OBTURATORS. 


1041 


of  a  gentleman  who  had  an  opening  through  the  hard  palate,  in  the 
centre  of  the  arch,  about  as  large  as  a  ten-cent  piece.  This  gentle- 
man had  worn  an  obturator  with  a  sponge  attached  to  it,  made  in 
the  following  manner:  a  plate  was  struck  up  to  fit  the  roof  of  the 
mouth,  and  a  piece  of  sponge  was  sewed  upon  the  palatine  surface, 
to  fill  the  opening,  and  to  hold  the  plate  in  its  place.  Some  of  the 
objections  to  this  obturator  were  that  the  opening  became  enlarged 
from  the  absorption  occasioned  by  the  pressure  of  the  sponge  upon 
the  sides  of  the  cavity  ;  it  would  also  become  very  offensive,  and  re- 
quire frequent  removal.  In  this  case  a  plate  was  struck  up  to  fit 
the  mouth,  and  attached  to  the  teeth  by  means  of  clasps.     This 

Fig.  336. 


■.,^„sa5ii' 


simple  appliance  answered  better  than  any  other  that  had  been  made 
for  him. 

"  The  second  case  was  that  of  a  gentleman  who  had  an  opening 
into  the  left  antrum,  at  the  point  where  the  second  bicuspis  and  the 
first  molar  had  been,  but  on  the  outer  surface  of  the  alveolar  ridge,  or 
rather  where  the  ridge  had  been — for  the  alveolus  was  entirely  ab- 
sorbed opposite  the  opening,  which  was  about  half  an  inch  in  length 
by  a  quarter  in  width.  The  nasal  bones  were  diseased,  which  caused 
an  almost  intolerable  odor. 

"  He  made  for  this  case  a  small  obturator  to  close  the  opening. 
This  was  left  open  at  the  top,  to  allow  him  to  place  in  it  a  small 
portion  of  chloride  of  lime.  His  intention  was  to  correct,  if  possible, 
the  offensive  smell,  but  the  patient  did  not  live  long  enough  to  give 

65 


1042 


ORAL  DISEASES  AND  SURGERY. 


it  a  fair  trial;  lie  remarked  that  while  any  of  the  chloride  of  lime 
remained  in  Ihe  obturator  there  was  no  unpleasant  smell ;  but,  unfor- 
tunately for  the  experiment,  the  gentleman  had  lost  nearly  all  the 
sense  of  smell,  and  therefore  could  not  tell  when  it  had  evaporated. 

"  He  made  for  this  case  an  upper  set  of  teeth,  to  which  the  obtu- 
rator was  secured,  it  being  held  in  position,  to  a  great  degree,  by 
the  plate  and  teeth. 

"  In  the  two  preceding  eases  the  voice  was  not  altered  when  the 
appliances  were  in  the  mouth. 

"  The  third  case  was  that  of  a  gentleman  who,  on  a  previous  occa- 
sion, had  a  tumor  removed  which  covered  a  portion  of  the  posterior 

Fio.  337. 


surface  of  the  hard  and  the  anterior  surface  of  the  soft  palate.  The 
surgeon,  on  its  removal,  had  divided  the  velum  and  uvula,  so  that  the 
case  resembled  a  congenital  deformity.  The  attempt  had  been  made 
twice  to  bring  the  soft  parts  together  again  by  a  surgical  operation, 
which  had  failed. 

"Fig.  337  shows  the  appearance  of  the  parts  very  clearly, — the 
letters  A  and  B  showing  the  thickened  muscles  as  they  hung  down 
on  the  side  of  the  pharynx. 

"  He  made  for  this  case  an  obturator,  Fig.  388,  the  plate  of  which 
covered  the  whole  of  the  roof  of  the  mouth,  with  a  bulb  attached,  to 


OBTURATORS. 


1043 


extend  up  into  the  posterior  nares  and  well  back  toward  the  antero- 
posterior walls  of  the  pharjnix,  leavin<,^  but  a  small  space  between 
them.  This  obturator  enabled  the  patient  to  eat  and  drink  without 
annoyance  ;  without  it  food  would  pass  into  the  nares  and  occasion 
much  inconvenience.  It  also  greatly  assisted  his  voice,  as  many  of 
his  words  could  not  be  understood  when  it  was  not  worn,  but  he 
could  articulate  them  with  great  distinctness  when  it  was  in  place. 

Fig.  338. 


Dr.  Buckingham  remarked  that  he  had  been  more  successful  in  re- 
storing the  voice  in  this  case  than  in  any  other  he  had  treated,  and 
attributed  it  to  the  fact  that  this  person,  having  once  had  his  voice 
perfect,  was  always  endeavoring  to  speak  as  he  had  formerly  done, 
wliile  in  the  congenital  cases  they  did  not  try  to  overcome  this 
difficulty. 

"  The  fourth  case  was  that  of  a  lady  who  had  an  opening  in  the 
anterior  part  of  the  hard  palate,  a  little  larger  than  a  ten-cent  piece, 
and  also  a  small  one  exposing  the  left  antrum.  All  the  teeth  in  the 
superior  arch  had  been  removed,  and  absorption  of  the  alveolar 
process,  opposite  the  smaller  opening,  had  progressed  to  such  an 
extent  as  to  present  at  that  point  a  deep  depression  ;  the  remaining 
part  of  the  alveolar  ridge  had  not  been  absorbed  more  than  is  usual 
where  the  teeth  have  been  lost. 

"  Fig.  339  shows  the  appearance  of  the  different  parts,  C  repre- 
senting the  smaller  opening,  and  D  the  larger  one ;  between  these 
two  points  was  the  depression  referred  to. 

"  This  lady  had  never  worn  any  mechanical  appliance,  but  had 
been  in  the  habit  of  closing  the  larger  opening  with  loose  cotton  or 
pieces  of  linen.  Without  having  it  filled,  she  could  scarcely  be 
understood  when  speaking.  He  made  for  this  case,  first,  a  plain 
plate  to  extend  over  both  the  openings,  but  not  into  them  ;  upon 
this  plate,  at  the  point  where  the  process  had  been  absorbed,  he 
arranged  wax  so  as  to  restore  the  alveolar  ridge  to  its  natural  full- 


1044 


OBAL  DISEASES  AND  SURGERY. 


ness.  By  using  the  plate  with  the  wax  attached  for  a  mould,  he 
was  able  to  obtain  metallic  dies.  A  second  plate  was  then  made 
to  fit  over  that  part  of  the  first  one  which  was  covered  by  the  wax ; 
these  two  plates  were  then  soldered  together.  The  object  in  forming- 
a  double  plate  was  to  till  up  that  part  where  absorption  had  taken 

Fig.  330. 


place,  so  that  the  plate  when  worn  would  resemble  the  roof  of  the 
mouth,  and  not  be  deeper  on  one  side  than  on  the  other. 

"  This  obturator  was  very  successful :  the  voice  was  much  im- 
proved, and  she  could  eat  and  drink  as  well  as  persons  ordinarily 
can  who  wear  upper  sets  of  teeth  ;  and,  what  was  more  remarkable, 
she  could  wear  it  without  springs  or  any  assistance  whatever  to 
retain  it  in  position. 

"He  stated  that  he  hnrdly  knew  whether  his  fifth  case  should 
come  under  discussion  at  the  present  time  or  not,  as  it  could  hardly 
be  termed  a  palatine  fissure  ;  but,  from  its  exceeding  interest,  he 
would  now  present  it. 

"A  gentleman  was  handling  a  gun  loaded  with  buckshot,  when 
it  was  discharged  in  his  hands.  The  gun  being  pointed  toward  his 
head  at  the  time,  the  load  struck  him  at  the  angle  made  by  the  ramus 
and  the  body  of  the  inferior  niaxillary  on  the  right  side,  passing  up- 
ward and  outward  on  the  opposite  side  of  the  face.  It  must  have 
been  a  terrible  wound,  and  should,  from  the  representation  given, 
have  caused  almost  instant  death.     He,  however,  recovered,  after 


OBTURATORS.  1045 

being  confined  to  his  bed  for  more  than  a  year,  and  during  that  time 
he  had  to  be  fed  with  a  spoon.  The  only  way  he  could  eat  or  drink 
was  to  lie  on  his  back  and  let  the  food  run  down  his  throat,  and  it 
was  a  long  time  before  he  found  he  could  swallow. 

"  The  teeth  in  the  upper  jaw  were  all  gone,  excepting  the  left  second 
molar  and  wisdom  tooth  ;  both  antra  were  fully  exposed,  the  remain- 
ing roof  of  the  mouth  being  left  almost  flat.  The  lower  jaw-bone  was 
gone  on  the  right  side,  from  the  second  bicuspid  back,  and  also  the 
condyloid  process  ;  but  about  three-quarters  of  an  inch  of  the  coro- 
noid  remained,  which  was  drawn  in  so  as  to  partially  cover  the  roof 
of  the  mouth.     The  molar  teeth  were  lost  on  the  left  side,  and  also 

Fig.  340. 


all  on  the  right  side  from  the  symphysis.  In  taking  hold  of  the 
lower  jaw  it  could  be  moved  either  backward,  forward,  or  laterally, 
to  a  considerable  distance. 

"  Figs.  340  and  341  show  this  case — the  letters  A  and  B  the  open- 
ings in  the  antrum,  and  C  the  end  of  the  lower  jaw-bone.  The  dis- 
tance between  the  points  A  and  C,  when  the  mouth  was  closed,  was 
just  two  inches. 

"  This  gentleman  had  been  wearing  a  partial  set  of  upper  teeth 
which  had  been  attached  to  the  molars,  but  the  clasps  of  the  artifi- 
cial teeth  had  loosened  them,  and  it  was  therefore  necessary  to  re- 
place the  piece  of  work  with  a  set  that  could  be  supported  in  some 
other  way. 


1046 


ORAL  DISEASES  AND  SURGERY. 


Fig.  341. 


"This  was  the  most  diflScult  case  he  had  ever  treated.  One  of 
the  greatest  obstacles  he  encouutered  was  the  obtaiuiug  of  a  cor- 
rect impression.  To  accomplish 
this,  he  first  filled  the  antra  with 
loose  cotton,  to  prevent  the  wax 
from  passing  into  them  ;  he  then 
took  as  good  a  wax  impression  as 
he  could  of  both  the  upper  and 
the  lower  jaws ;  from  these  he 
made  impression-cups  to  be  used 
in  taking  the  plaster  impressions. 
There  was  very  little  difficulty  in 
obtaining  an  iu)pression  of  the  up- 
per jaw  with  plaster  (the  antra 
being  filled  with  cotton  as  before), 
but  it  was  far  more  difficult  to 
take  a  good  one  of  the  lower  jaw. 
The  distance  from  the  points  of  the  teeth  down  to  the  point  marked 
C,  as  shown  in  Fig.  34(1,  was  so  great  that  when  any  material  was 
forced  down  to  take  the  impression,  it  was  almost  impossible  to  re- 
move it  from  the  mouth  without  altering  it  so  much  as  to  render  it 
of  no  value.  After  several  trials,  he  succeeded  in  getting  a  very 
good  one  with  plaster.  It  had  to  be  broken  before  its  removal  from 
the  mouth;  but,  by  carefully  putting  the  pieces  together,  a  good 
cast  was  obtained. 

"  He  then  made  a  plate  to  extend  over  the  roof  of  the  mouth  and 
cover  both  of  the  cavities  opening  into  the  antra ;  on  this  plate  he 
arranged  wax,  bringing  it  down  as  far  as  the  alveolar  ridge  should 
have  been  ;  then  made  a  metal  cast  and  struck  another  plate  to  fit 
over  the  first,  soldered  them  together,  and  placed  upon  these  single 
gum  teeth  as  he  would  have  done  had  there  been  no  more  absorption 
than  is  usually  found  in  upper  cases. 

"There  was  nothing  peculiar  in  the  formation  of  the  lower  case, 
except  that  the  teeth  had  to  be  very  long  on  the  right  side  (for  this 
a  block  was  made),  and  the  plate  was  not  allowed  to  extend  farther 
back  than  to  the  position  once  occupied  by  the  second  bicuspid  tooth. 
The  under  teeth  were  put  in  more  for  the  purpose  of  attaching 
springs  for  the  support  of  the  upper  ones  than  for  use. 

"  He  could  not  say  what  success  had  attended  this  case,  as  the 
gentleman  left  the  city  immediately  upon  their  insertion,  and  he  had 
not  seen  him  since  that  time." 


OBTUBATORS.  1047 

Other  cases  of  equal  interest  are  found  in  tlie  report;  but,  as  they 
are  unaccompanied  by  models,  I  omit  them. 

A  material  for  obturators  is'fast  winning  its  way  to  professional 
favor  in  the  article  known  as  vulcanite.  This  is  the  base  now  so 
extensively  used  in  the  manufacture  of  sets  of  teeth.  Its  merits 
and  demerits  are  widely  discussed  in  all  the  dental  publications  of 
the  day,  and  from  these  journals  everything  pertaining  to  it  may  be 
gleaned.  The  advantages  claimed  for  it  are  :  its  cheapness,  its 
lightness,  its  capability  of  being  moulded  into  the  most  irregular 
positions,  and  its  resemblance  in  color  and  feel  to  the  natural  parts. 
The  objections  are  its  liability  to  decompose  and  l)ecome  offensive. 
The  manipulation  of  the  material  is  so  easy  that  the  surgeon  at- 
tempting the  manufacture  from  it  of  surgical  appliances  would  give 
himself  a  source  of  recreation  rather  than  work.  To  make  an  ob- 
turator from  vulcanite,  you  take  an  impression  of  the  mouth  in  wax 
and  make  from  it  a  plaster  model  precisely  as  before  described. 
Prepared  gutta-percha  is  now  moulded  over  this  model  to  the  form 
required.  Plaster  is  next  run  over  this  first  model,  the  gutta-percha 
plate  being  between.  The  model  and  counter-model  thus  made  are 
separated,  and  the  place  of  the  original  plate  supplied  with  fresh 
vulcanite.  The  models  are  now  put  together,  and  the  vulcanite 
between  subjected  to  pressure.  The  whole  is  then  placed  in  an  ap- 
paratus termed  the  vulcanizer,  and,  filling  this  with  water,  the  tem- 
perature is  raised  to  about  3"25  degrees.  When  taken  from  the  steam- 
bath  the  plate  is  found  to  be  as  hard  as  bone.  The  last  process 
consists  in  the  polishing  of  the  piece;  this  is  a  simple  manipulation, 
and  requires  only  one  or  two  files,  a  burnisher,  and  some  patience. 

M.  Desirabode,  a  French  surgeon,  proposes  a  palatine  obturator 
for  congenital  fissure  of  the  palate,  by  which  he  thinks  the  sides  of 
the  alveolar  border  may  be  so  approximated  as  to  favor  a  union  of 
the  divided  parts.  It  consists  of  a  platina  plate  fitted  to  the  vault 
of  the  palate  and  fastened  to  the  teeth  by  means  of  three  clasps 
soldered  to  each  side,  so  as  to  cap  the  canine  teeth,  the  bicuspid, 
and  tw^o  of  the  molar  teeth,  bent  upon  the  alveolar  border  in  such  a 
manner  as  to  maintain  the  whole  pressure.  After  the  plate  with  these 
appendages  has  been  well  adapted,  it  is  to  be  divided  from  before 
backward  along  the  median  line,  and  then  a  piece  removed  from  either 
side  so  that  the  two  edges  may  be  separated  about  half  an  inch  from 
each  other.  The  two  plates  are  now  united  by  means  of  a  thick  and 
resisting  baud  of  caoutchouc,  made  fast  by  riveting.  The  plates  thus 
united  form  a  smaller  obturator  than  the  plate  before  it  was  divided, 


1048  ORAL  DISEASES  AND  SURGEBY.^ 

so  that  it  can  only  be  applied  by  putting  the  caoutchouc  on  the 
stretch,  which  is  effected  by  means  of  two  sticks  so  contrived  as 
to  force  the  plates  asunder.  After  the  plate  is  properly  adjusted, 
these  are  removed,  when,  by  the  contraction  of  the  caoutchouc,  the 
sides  of  the  alveolar  borders  are  gradually  approximated. 

This  contrivance  of  Desirabode  looks  very  plausible,  but,  unfor- 
tunately, all  experience  is  against  its  employtneut. 

In  the  first  place,  to  correct  by  pressure  a  fissure  in  the  hard 
palate  implies  the  very  earliest  use  of  such  force,  A  child  is  five 
or  six  years  old  before  its  first  dentition  is  properly  completed; 
and  even  at  this  period  one  would  not  dare  to  apply  any  such 
apparatus,  because  of  the  physiological  process  of  absorption  which 
has  already  commenced  in  certain  of  the  teeth.  Then  if,  on  the  con- 
trary, he  meant  his  instrument  to  apply  to  a  more  advanced  period, 
he  would  have  to  wait  until  at  least  the  sixteenth  year,  as  before 
this  age  the  fangs  of  the  molars  are  not  perfected.  The  bones  by 
this  time  have,  as  a  matter  of  course,  become  much  less  amenable 
to  treatment.  And  again,  even  besides  this,  as  I  know  from  practical 
teachings,  his  apparatus  would  in  less  than  a  week's  time  produce 
such  periosteal  trouble  about  the  alveoli  tiiat  no  human  being  would, 
or  could,  bear  the  contintiaiice  of  the  pressure;  or,  even  admitting 
there  should  be  found  a  patient  heroic  enough  to  bear  the  treatment, 
the  apparatus  would  have  its  usefulness  destroyed  in  less  than  two 
weeks  by  the  teetl),  to  which  it  was  attached,  coming  away.  In 
other  words,  the  instrument  is  useless,  because  ihe  teeth,  being  the 
weaker  and  more  yielding,  would  give  way  first. 

In  Listen  and  Miitter's  Surgery  is  an  engraving  of  an  obturator 
made  to  supply  the  loss  of  both  hard  and  soft  palates.  The  con- 
trivance, which  is  a  simple  plate  such  as  has  been  described,  is  seen 
to  extend  from  the  teeth  back  to  the  fauces.  Attached  to  the  back 
portion  of  the  plate  representing  the  soft  palate  is  a  metal  pendulum 
working  on  a  hinge  ;  this  pendulum  is  much  better  omitted,  for, 
while  it  cannot  possibly  answer  any  useful  purpose,  it  must  certainly 
be  much  in  the  way.  In  making  so  extensive  an  obturator,  it  is  not 
to  be  forgotten  that  the  part  which  represents  the  soft  palate  is  to 
be  given  the  double  curve  which  is  seen  on  looking  into  any  healthy 
mouth.  To  get  the  impression  for  such  an  obturator,  we  have  to 
employ  a  very  deep  impression-cup. 

Dr.  E.  Wildman,  of  the  Pennsylvania  College  of  Dental  Surgery, 
kindly  furnishes  me  with  a  description  and  cuts  of  a  case,  which,  as 
a  study,  will  well  repay  attention.    The  patient  I  have  myself  seen. 


OBTURATORS. 


1049 


Fig.  342  will  convey  an  idea  of  the  external  appearance  of  the 
patient,  but  not  fully,  as  the  whole  upper  lip  was  cicatrized,  and 
the  left  cheek  depressed  near  the  border  of  the  cavitv. 

Fig.  342. — The  Face  without  Nose. 


"  In  May,  18G3,  a  young  man,"  says  Dr.  "Wildnian,  "  aged  twenty- 
six  years,  presented  himself  for  the  purpose  of  having  an  appliance 
made  to  repair  a  loss  sustained  by  disease.  Upon  removing  the 
black  patch  which  he  wore  upon  his  face,  and  the  cotton  with  which 
the  cavity  was  filled  (without  the  latter  he  could  not  articulate  a 
word),  I  found  that  the  entire  external  nose  was  gone, — that  the 
nasal  bones,  the  nasal  processes  of  the  superior  maxillary,  also  a 
large  portion  of  their  palatine  processes,  the  approximal  parts  of 
the  palatine  processes  of  the  palatine,  and  the  turbinated  bones,  had 
been  destroyed.  The  soft  palate,  the  uvula,  and  the  tousils  were 
uninjured. 

"  In  looking  into  the  nasal  cavity,  the  walls  of  the  antrum  on  the 
left  side  were  found  deficient,  and  ends  of  the  roots  of  the  incisors 
exposed  and  decayed.  The  tongue  was  visible  through  the  opening 
in  the  palatine  arch.  The  size  and  shape  of  this  orifice  are  repre- 
sented by  the  outer  central  Hue  in  Fig.  343. 


1050 


OEAL  DISEASES  AND  SURGERY. 


"  Although  desirable,  it  was  deemed  unsafe  to  remove  the  diseased 
roots,  owing  to  the  yielding  nature  of  the  superior  maxillary  bones. 

Fig.  343. — Internal  View  of  Superior  Arch. 


The  disease  appeared  to  be  arrested,  and  the  parts  in  a  sufficiently 
healthy  condition  to  warrant  the  ajiplication  of  the  substitute;  and 
time  has  verified  this,  as,  with  the  exception  of  the  exfoliation  of  a 
small  scale  from  one  of  the  superior  maxillary  bones,  about  nine 
months  since,  no  change  has  taken  place  up  to  this  date. 

"  The  first  step  in  the  operation  was  to  procure  an  impression  that 
would  enable  me  to  make  a  perfect  model  of  all  the  parts  involved, 
and  their  surroundings,  in  their  relative  positions.  For  this  purpose 
plaster  was  best  adapte.d,  but  its  use  was  precluded  by  the  acrid  se- 
cretions in  the  nasal  cavity ;  wax  and  paraffin  was  considered  the 
best  substitute,  and  used.  Owing  to  the  rigidity  of  the  upper  lip,  I 
was  unable  to  use  the  ordinary  impression-cup  with  success,  and 
was  obliged  to  take  a  rough  impression  of  the  palatine  arch,  from 
which  a  model  was  made,  and  a  metallic  impression-cup  swaged. 

"A  sufficient  quantity  of  paraffin  and  wax  was  placed  in  warni 
water,  and,  with  an  assistant  to  keep  it  at  the  proper  temperature, 
the  mode  of  procedure  was  as  follows:  a  proper  quantity  of  the  com- 
pound was  placed  in  the  cup,  introduced  into  the  mouth,  and  pressed 
up  firmly  against  the  arch ;  the  part  forced  into  the  palatine  fissure 


OBTURATORS.  1051 

was  at  the  same  time  pressed  with  the  finder,  introduced  through 
the  nasal  cavity,  so  that  it  should  give  an  accurate  impression  of  its 
lateral  borders.  A  groove  was  then  cut  in  this  to  serve  as  a  key, 
and,  after  oiling  it,  a  piece  of  the  compound  was  introduced  through 
the  orifice  of  the  nasal  cavity,  and  passed  down  to  make  the  impres- 
sion of  the  floor  of  the  nasal  cavity.  When  sufficiently  hard,  it  was 
carefully  removed,  the  upper  surface  trimmed,  placed  in  cold  water 
to  give  it  its  greatest  firmness,  then  introduced  into  the  cavity,  and 
pressed  into  its  proper  position.  The  metallic  cup  containing  the 
impression  of  the  palatine  arch  was  then  removed.  The  next  step 
was  to  take  an  impression  of  the  sides  of  the  cavity,  then  the  top, 
using  a  curved  wooden  spatula  to  press  the  compound  in  proper  posi- 
tion, being  careful  to  mark  or  key  the  parts  that  came  in  contact, 
and  have  their  surfaces  oiled,  to  prevent  adhesion  ;  and  also  thattlie 
pieces  should  be  thinner  in  front  than  in  their  posterior  parts,  so  that 
when  the  four  pieces  forming  the  impression  of  the  base,  sides,  and 
top  were  in  their  proper  position,  they  would  leave  a  tapering  cavity, 
with  its  largest  diameter  at  the  front  orifice.  Into  this  orifice  was 
forced  a  plug  or  cone  of  the  compound,  filling  it  completely,  in  the 
front  of  this  piece  were  inserted  pieces  of  match  sticks,  to  cause  it  to 
adhere  to  the  next  piece  or  mask.  The  head  was  now  thrown  back 
to  nearly  a  horizontal  position,  wet  tissue-paper  was  placed  over  the 
eyebrows  and  lashes,  the  face  oiled,  and  plaster  mixed  thick  was 
batted  on  with  a  brush.  When  set,  this  was  removed,  drawing  with 
it  the  central  plug  or  cone ;  the  different  parts  were  then  carefully 
removed,  and  thrown  into  cold  water  to  give  them  a  consistency  to 
bear  handling  without  danger  of  injury.  On  this  central  cone  all 
the  parts  were  placed  in  their  proper  position,  and  the  impression  of 
the  palatine  arch  was  adjusted  in  its  proper  place.  From  this  a 
plaster  model  was  made,  giving  the  upper  part  of  the  face,  cavities, 
palatine  arch,  all  correctly  in  their  relative  positions. 

"  Of  the  different  substances — leather,  wood,  wax,  metal  enameled, 
and  porcelain — used  for  making  artificial  noses,  I  gave  the  preference 
to  hard  rubber  in  this  case,  on  account  of  its  rigidity,  strength,  light- 
ness, and  less  liability  to  injury  by  accident.* 

"  To  prevent  derangement,  it  was  necessary  to  make  the  appliance 
as  simple  as  possible;,  it  consisted  of  two  pieces:  the  external  nose, 

*  Aluminium,  the  author  thinks,  will  eventually  be  much  used  for  all  this 
class  of  operations:  it  is  light,  soft,  easily  worked,  and  may  be  beautifully  en- 
ameled. When  corrugated  or  bent  into  the  form  of  a  nose,  it  is  as  resisting  as 
eigbteen-carat  gold-plate. 


1052 


ORAL  DISEASES  AND  SURGERY. 


septum,  and  floor  of  the  nasal  cavity  constituted  one,  having  a  pro- 
jection passing  downward  into  the  palatine  fissure,  as  represented  in 
Figures  343  and  344,  A;  and  the  other,  the  obturator  B,  Fig.  345, 
with  a  projection  rising  upward  into  the  palatine  fissure.     These 

Figs.  344  and  345. — Nose  avith  Attachments. 


projections  were  made  hollow,  so  that  when  the  two  i)arts  were 
placed  together,  as  in  Fig.  344,  there  would  be  a  cavity  or  box 
wherein  the  attachments  could  be  placed. 

"Models  were  made  of  the  compound  of  paraffin  and  wax,  which 
were  strengthened  in  the  weaker  parts  by  imbedding  small  strips  of 
metal  in  their  substance  to  give  sufficient  firmness  to  admit  of  the 
necessary  handling  without  injury.  The  model  was  applied  to  the 
patient,  and  the  nose  trimmed  so  as  to  harmonize  with  his  features. 
They  were  then  imbedded  in  plaster  in  the  usual  manner  for  vulcan- 
ite work,  with  the  exception  that  a  stout  curved  wire  passed  through 
the  artificial  nasal  cavities,  extending  beyond  their  borders,  to  give 
strength  to  the  rods  of  plaster  forming  these  cavities  in  the  matrix, 
and  thus  to  prevent  their  fracture  in  packing. 

"  This  appliance  was  vulcanized  four  hours,  consuming  one  hoiir 
in  attaining  280°  Fahr.,  at  which  point  it  was  held  one  hour,  and 
occupying  the  third  hour  in  elevating  the  temperature  to  320°,  where 
it  was  retained  one  hour.  The  work  was  rather  overdone,  but  not 
so  much  so  as  to  injure  it. 


OBTURATORS. 


1053 


"  The  two  pieces  were  retained  in  position  by  a  staple  and  slide- 
bolt.  In  the  recess  of  the  part  of  the  floor  of  the  nasal  cavity  pro- 
jecting into  the  palatine  fissure  (A,  Fig.  344)  was  inserted  a  gold 
staple.  In  the  recess  of  the  projection  of  the  obturator  passing  into 
the  palatine  fissure  (B,  Fig.  345)  were  the  gold  catch  and  shield  of 
the  slide-bolt.  The  object  of  this  shield  was  to  prevent  any  foreign 
substance  entering  the  slot  and  obstructing  the  movements  of  the 
bolt,  also  to  give  a  base  of  support  to  the  catch.  The  rectangular 
upright  of  the  catch  was  soldered  to  the  shield,  passed  through  it 
and  a  longitudinal  slot  in  B,  and  securely  fastened  to  a  rubber  slide 
inlaid  longitudinally,  and  moving  freely  in  the  lingual  surface  of  the 
obturator.  On  the  anterior  end  of  this  slide  was  a  small  rounded 
projection,  which  enabled  the  patient,  when  the  two  parts  of  the 
appliance  were  placed  in  their  proper  position,  with  the  point  of  a 

Fig.  346. — The  Face  with  Nose. 


finger  introduced  into  the  mouth,  to  force  the  slide  backward,  thereby 
to  pass  the  catch  into  the  staple  and  firmly  secure  the  apparatus,  or, 
by  drawing  the  slide  forward,  detach  the  parts  when  desirable  to 
remove  them. 


1054  ORAL  DISEASES  AND  SURGERY. 

"The  external  nose  was  painted  with  oil  color,  to  give  it  as  nearly 
a  flesh  tint  as  possible,  although  this  is  not  attainable  upon  an 
opaque  ground.  Flesh  being  translucent,  a  true  imitation  can  only 
be  made  upon  a  translucent  ground. 

"The  apparatus  was  introduced  on  June  30,  1863,  giving  to 
the  patient  great  satisfaction  and  comfort.  His  appearance  was 
much  improved,  as  may  be  judged  by  comparing  Figs.  342  and  346, 
which  were  engraved  from  photographs.  He  breathes  freely  through 
the  nose,  and  speaks  with  ease;  the  only  imperfection  in  his  speech  is 
a  nasal  twang,  and  this  is  less  now  than  when  the  instrument  was 
first  applied.  The  obturator  at  first  extended  too  far  back,  and  caused 
some  irritation  of  the  velum  :  this  defect  was  readily  remedied. 

"  The  operation  proved  entirel}'  satisfactory,  with  two  exceptions: 
first,  the  color  of  the  nose  was  not  as  natural  as  desirable,  for  the 
reason  already  stated  ;  second,  in  deglutition  and  speech,  when  the 
tongue  pressed  forcibly  against  the  posterior  part  of  the  obturator, 
an  unpleasant  vibratory  movement  of  the  apex  of  the  nose  was 
noticeable.  This  could  have  been  remedied  by  an  elastic  attach- 
ment coupling  the  two  parts  of  the  apparatus,  but  this  mode  was 
objectionable  by  reason  of  its  producing  constant  pressure  upon  the 
delicate  parts,  and  thereby  endangering  absorption.  A  safer  plan 
was  adopted  by  inserting  a  small  steel  pin  in  the  nose  as  near  as 
possible  to  its  apex,  to  which  was  attached  the  bridge  of  a  pair  of 
spectacle-frames,  these  being  retained  in  position  by  an  elastic  cord 
attached  to  the  bows  and  passing  around  the  head.  This  arrange- 
ment answered  the  double  purpose  of  counteracting  the  viijratory 
movement,  and  the  bridge  of  the  frames  concealing  the  upper  part 
of  the  joint  where  the  nose  came  in  contact  with  the  face,  which 
was  most  conspicuous. 

"  This  apparatus  is  worn  with  ease  and  comfort  by  the  patient." 

The  obturator,  although  employed  by  the  ancient  Greeks,  and  by 
every  succeeding  generation  of  civilized  men,  seems  to  have  attained 
to  its  wonderful  completeness  onh'  in  our  own  age.  Before  the 
time  of  Ambrose  Pare,  the  appliances  were  all  of  a  temporary 
nature,  if  we  except  mention  of  one  suggested  by  Petrouius,  in  the 
sixteenth  century,  although  whether  this  surgeon  ever  really  made 
such  a  plate  as  he  described,  we  are  not  informed.  To  Pare,  how- 
ever, we  are  indebted  for  a  written  description  of  the  metal  obturator, 
crude,  without  doubt,  but  embracing  the  principles  of  the  present 
instruments,     "Made,"   says  this  surgeon,   "like  unto  a  dish  in 


OBTUBATORS.  1055 

figure,  and  on  the  upper  surface,  which  shall  be  toward  the  hair,  a 
little  sponge  must  be  fastened,  which,  when  it  is  moistened  with  the 
moisture  distilling  from  the  brain,  will  become  swollen  and  puffed, 
so  that  it  will  fill  the  concavity  of  the  palate,  that  the  artificial 
palate  cannot  fall  down,  but  stand  fast  and  firm  as  if  it  stood  of 
itself." 

Garangeot,  in  1715,  made  an  advance  oil  the  idea  of  Pare, — al- 
though, it  must  be  admitted,  a  very  slight  one.  He  describes  his 
instrument  as  having  a  stem  in  the  form  of  a  screw,  upon  which 
ran  a  nut.  To  make  use  of  it,  he  cut  a  piece  of  sponge  in  the  form 
of  a  hemisphere,  with  a  flat  surface ;  through  this  sponge  the  stem 
was  passed,  the  nut  holding  it  in  place.  When  about  to  introduce 
it,  he  wet  the  sponge,  then  squeezed  it  dry,  and  forced  it  through 
the  aperture  or  break. 

After  the  period  of  Garangeot,  no  special  advances  seem  to  have 
been  made  until  1828,  when  obturators  were  constructed  by  a  Mr. 
Snell,  prepared  on  casts,  which  were  correct  representations  or  im- 
pressions of  the  special  cases.  In  a  monograph  published  by  this 
surgeon,  he  says,  "My  method  of  constructing  an  obturator  is  with 
a  gold  plate,  accurately  fitted  to  the  roof  of  the  mouth,  extending 
backward  to  the  os  palati,  or  extremity  of  the  hard  palate  ;  a  part  of 
the  plate,  about  an  inch  in  length,  being  carried  through  the  fissure. 
To  that  part  of  the  plate  which  answers  to  the  nasal  fossse  are  sol- 
dered two  plates,  meeting  in  the  centre  and  carried  upward  through 
the  fissure  to  the  top  of  the  remaining  portion  of  the  bones,  to  which 
it  should  be  exactly  adapted,  and  made  to  the  natural  shape  of  the 
nasal  palatine  floor:  thus  the  fluids  of  the  mouth  will  be  carried 
backward  into  the  fauces.  A  piece  of  prepared  elastic  gum  is  next 
attached  to  the  posterior  part  of  the  plate  where  the  natural  soft 
palate  commences,  extending  downward  on  each  side  as  low  as  the 
remaining  part  of  the  uvula,  and  grooved  at  its  lateral  edges  to  re- 
ceive the  fissured  portions  of  the  velum  ;  a  movable  velum  is  placed 
in  the  posterior  centre  of  the  elastic  gum.  That  these  may  partake 
of  the  natural  movements  of  the  parts  during  deglutition,  a  sponge 
is  affixed  behind  them,  one  end  of  which  is  attached  to  the  posterior 
and  anterior  surfaces  of  the  principal  plate,  and  the  other  end  rests 
gently  against  the  posterior  face  of  the  india-rubber;  this  keeps  it 
always  in  close  apposition  with  the  edges  of  the  fissure  during 
deglutition. 

"  It  is  requisite  to  mention,"  he  says,  "  that  the  elastic  gum 
should  be  placed  in  a  gold  frame,  and  not  merely  fastened  to  the 


1056 


ORAL  DISEASES  AND  SURGERY. 


posterior  part  of  the  plate,  as  it  would  shrink  up  by  remaining  in 
the  mouth.  This  frame  should  pass  round  its  edges  only,  leaving 
the  centre  upon,  etc." 

In  1845,  Mr.  Stearn,  a  surgeon  of  London,  conceived  the  idea  of 
an  obturator,  the  principle  of  which  has  been  brought  to  great  per- 
fection by  Dr.  Xorman  Kingsle}'',  of  New  York.*  This  appliance, 
as  made  by  Mr.  Stearn,  consisted  of  a  gold  plate  fitted  to  the  hard 
palate,  having  attached  to  it,  by  means  of  two  spiral  springs,  an 
artificial  velum  of  elastic  rubber,  consisting  of  a  body,  wings,  and 
grooved  edges,  to  receive  the  margin  of  the  cleft.  The  conception 
of  this  obturator  reflects  great  credit  upon  Mr.  Stearn,  an  honor 
which  Dr.  Kingsley  may  feel  it  no  detraction  to  share  with  him. 

The  perfected  instrument  of  Dr.  Kingsley,  though  differing  greatly 
from  that  of  Mr.  Stearn,  consists  likewise  of  a  body  with  mova- 
ble wings.  These  wings,  made  of  soft  rubber,  fill  up  the  break  in 
the  soft  palate,  being  moved  by  the  lateral  remnants  of  the  defective 
parts. 

With  respect  to  this  obturator,  so  much  experience  seems  to  have 
accumulated  that  its  great  usefulness  can  no  longer  be  doubted. 


Fig.  347. 


Fig.  348. 


Fig.  347  is  here  again  introduced  as  a  study  in  mechanical  appli- 
ances.   This  figure  represents  the  patient  as  first  seen  by  the  author. 


*'Dupuytren,  the  eminent  French  surgeon,  is  not,  it  seems  to  me,  without 
some  claim  to  a  share  in  this  invention :  his  idea,  however,  was  very  crude. 


OBTURATORS. 


1057 


Fig.  349. 


Fig.  348,  although  not,  taken  from  the  case,  is  yet  wonderfully- 
correct  as  a  likeness  after  treatment  of  the  lip,  as  described  and 
illustrated  on  pages  988  and  989. 

Fig.  349  is  from  a  photograph 
taken  after  treatment  of  the  case 
was  completed  by  adaptation  of 
an  artificial  nose,  which,  with  the 
assistance  of  the  ingenious  surgical 
artist,  Mr,  Kemble,  was  prepared 
for  her.  In  this  case,  the  nose  is 
temporarily  employed  in  anticipa- 
tion of  a  more  promising  condi- 
tion for  restoration  of  the  organ 
by  operation.  The  efiFect  is  even 
better  than  is  shown  in  the  photo- 
graph, the  nose  having  since  been 
elaborately  painted  by  an  eminent  portrait-painter.* 

Fig.  350  represents  an  artificial  nose,  together  with  a  common 
manner  of  holding  the  piece  in  place.  In  employing  springs.  A,  A, 
as  here  shown,  great  care  is  to  be  ex- 
ercised that  pressure  be  so  applied  as 
to  insure  if  possible  against  an  irrita- 
tion which  is  apt  to  result  either  in 
inflammation  or  absorption  of  the 
tissues,  thus  in  a  double  direction 
rendering  the  piece  useless.  Better, 
however,  than  the  upper  spring  for 
fixing  the  piece  is  the  use  of  a  pair  of 
spectacles  ;  these,  through  the  employ- 
ment of  an  elastic  band  passed  around  the  head,  not  only  prevent  all 
motion  on  the  part  of  the  artificial  nose,  but  also  conceal  the  line 
of  break.  The  author  is  satisfied  that  the  use  of  the  spectacles  is 
the  best  means  of  fixedness  yet  devised. 

In  gentlemen  wearing  whiskers  and  moustache,  the  lower  spring 
is  also  to  be  replaced  by  means  of  a  delicate  silver  wire  painted  the 
color  of  the  beard,  and  kept  tense  by  relation  of  the  two  ends  through 
the  elastic  bandage,  concealed  by  the  hair  as  it  passes  around  the 
head. 


Fig.  350. 


*  The  cut  differs  from  the  photograph  only  as  parts  aside  from  tlio  scat  of 
operation  are  concerned,  it  being  necessary  to  prevent  a  recognizable  lilvcnei=s. 

66 


CHAPTER     LI. 

RESECTIONS   OF   THE   MAXILLARY   BONES. 

The  history  of  experimental  surgery  upon  the  bones  of  the  face 
constitutes  one  of  the  most  interesting  of  the  chapters  in  surgery. 
The  formation  upon  and  within  these  bones  of  such  diseases  as 
seemed  to  make  desirable  their  removal,  necessarily  directed,  from  a 
comparatively  early  period,  the  attention  of  surgeons  to  the  feasi- 
bility, propriety,  and  promises  of  such  operations. 

It  is  not  at  all  unreasonable  to  infer  that  surgery  gained  its  first 
lesson  in  this  direction  by  observing,  through  the  results  of  acci- 
dents, bow  extensive  could  be  an  injury  done  to  these  parts  Avithout 
fatal,  or,  indeed,  even  threatening  consequences.  Hence,  as  early 
as  1693,  Acoluthus,  a  surgeon  of  Breslau,  attempted  the  removal  of 
a  portion  of  the  upper  jaw  for  a  tumor,  in  which  operation  he  suc- 
ceeded very  satisfactorily.  Jourdan,  according  to  his  translator, 
removed,  at  various  times  during  his  century,  portions  of  the  jaw. 
To  Dr.  Jameson,  an  American  surgeon,  however,  most  are  agreed, 
belongs  the  credit  of  having  made  the  first  complete  resection  or 
removal  of  the  upper  jaw, — this  having  been  done  in  1820,  although 
to  Lizars,  of  Edinburgh,  belongs  the  higher  credit  of  having  first  sug- 
gested the  possibility  and  advantage  of  the  operation.  In  1824,  four 
years  later.  Dr.  David  Rogers,  of  New  York,  resected  both  superior 
maxillae.  Afterward  this  was  attempted  by  Li2Mirs,  and  in  the  same 
year  by  Gensoul,  of  France.  After  this  the  operations  may  be 
considered  as  having  become  commonly  recognized,  surgeons  of 
ability  performing  the  various  sections  throughout  England  and 
France,  and  especially  in  the  United  States. 

While  the  operation  of  resection  has  been  frequently  performed, 
it  cannot  but  surprise  the  surgeon  of  to-day  to  notice  how  slowly  its 
lessons  were  learned.  At  present  it  is  practiced  with  little  prelimi- 
nary caution,  being  esteemed  an  operation  that  may  be  performed 
with  really  little  danger  to  the  patient,  and  even  without  much 
damage  to  the  appearance.  Formerly,  and,  indeed,  not  very  far 
back,  it  was  considered  only  safe  to  ligate,  as  a  preliminary  step, 
(1058) 


RESECTIONS  OF  THE  MAXILLARY  BONES.    1059 

the  primitive  carotid  artery;  and  when,  as  experience  advanced, 
this  was  seen  not  to  be  a  necessity,  the  actual  cauterants  were 
always  held  in  readiness,  a  practice  which,  much  to  the  detriment 
of  a  happy  cure,  obtains  in  some  sections  even  to  the  present  day. 

Resections  of-  the  maxillary  bones  are  practiced  for  various  dis- 
eases, the  principal  of  which  are  the  malignant  tumors.  That  such 
resections  are  so  often  reported  as  unfavorable,  has  not  been  from 
shock,  or  any  local  injury  done,  but  from  the  fact  that  the  disease 
for  which  the  operation  was  performed  was  in  itself  fatal. 

In  looking,  after  an  interval  of  months,  and,  in  a  few  cases,  of 
years,  at  individuals  upon  whose  jaws  the  author  has  personally  per- 
formed resections,  he  has  been  astonished  at  the  correction,  on  the 
part  of  nature,  of  deformity.  The  little  German  boy,  alluded  to  in 
the  chapter  on  Necrosis  as  having  lost  the  left  half  of  the  inferior 
maxilla,  without  at  the  time  any  reproduction,  looks  to-day  as  though 
no  such  loss  had  ever  occurred  ;  his  face  is  exactly  as  it  was  before 
the  operation,  and,  so  far  as  may  be  judged,  the  ability  to  masticate, 
allowing  for  the  loss  of  the  teeth  on  that  side,  is  about  as  good  as 
ever.  This,  however,  is  an  uncommon  case,  the  result  without 
doubt  of  the  youth  of  the  patient. 

Oilier,  by  his  experiments  upon  the  osteogenetic  properties  of  the 
periosteum,  has  done  good  service  to  oral  surgery.  It  is  now  a 
common  practice  in  all  resections  to  spare  and  save  all  this  tissue 
possible.  In  the  chapter  on  Necrosis  the  author  has  alluded  to  his 
own  success  in  this  direction,  having  replaced  entirely,  with  the 
exception  of  the  alveolar  process  and  teeth,  the  whole  of  the  body 
of  the  lower  jaw  through  the  process  of  enucleation. 

It  is  not  to  be  forgotten,  however,  that  the  seeds  of  a  disease,  so 
to  speak,  may  be  left  in  a  part  by  an  attempted  preservation  of  peri- 
osteal tissue.  This  fact  is  always,  in  all  classes  of  resection,  to  be 
borne  prominently  in  mind:  periosteal  tissue  is  not  to'  be  saved 
unless  healthy. 

To  make  a  complete  resection  of  either  maxilla  implies,  ordinarily, 
a  preliminary  uncovering  of  the  affected  bone.  The  incisions  to 
such  ends  are  necessarily  various,  being  influenced  by  the  condition 
of  the  parts  beneath.  They  are  not,  however,  always  necessary. 
Prof  Horner,  as  exhibited  in  Plate  XVII.,  has  removed  the  upper 
jaw  of  the  left  side  without  preliminary  incision ;  and  in  two  favor- 
able cases  I  have  myself  succeeded,  without  difficulty,  in  doing  the 
same  thing. 

In  the  case  of  tumors  of  magnitude  and  importance,  these  sub- 


1060  ORAL  DISEASES  AND  SURGERY. 

integumental  operations  are  not,  however,  to  be  commended.  A 
wound,  or  incision,  made  to  expose  such  tumors,  may  be  united  by 
the  first  intention,  leaving  little  or  no  scar,  while  certainly  the  ex- 
posure obtained  through  such  incisions  compensates  by  the  liberty 
and  rapidity  of  movement  allowed  in  the  subsequent  steps  of  an 
operation. 

Subfig.  1,  Plate  XYII.,  exhibits  the  mouth  of  the  patient  of  the  late 
Dr.  Horner,  immediately  after  the  removal  of  the  superior  maxillary 
bone  without  external  incision.  Fig.  2  is  a  side  view  of  the  bone 
removed,  and  Fig.  3  is  the  likeness  of  the  patient  taken  three  years 
after  the  operation.  The  operation,  as  practiced  by  Dr.  Horner,  is 
thus  described  by  his  son-in-law,  Prof.  Smith  :  "  Having  determined 
to  avoid  cutting  through  the  cheek,  as  commonly  practiced,  the  pa- 
tient was  seated  in  a  chair,  with  his  head  well  supported,  and  par- 
tially etherized.  The  assistant,  supporting  the  patient's  head,  then 
raised  the  angle  of  the  mouth  on  the  left  side,*  and  held  it  widely 
open,  while  the  upper  lip  and  cheek  were  dissected  from  the  superior 
maxilla  as  far  back  as  possible,  in  a  line  parallel  with  the  superior 
margin  of  the  buccinator  muscle.  The  two  incisor  teeth  on  the  left 
side  being  then  drawn,  the  corresponding  alveoli  were  cut  through 
in  the  middle  line  by  a  narrow  saw,  which  worked  its  way  from  the 
mouth  into  the  left  nostril ;  then  a  pair  of  strong  hawk-bill  scissors, 
such  as  are  used  by  gardeners  for  lopping  ofif  twigs,  took  out  the  two 
vacated  alveoli  at  a  clip. 

"  A  thin,  flat,  well-tempered  knife,  with  a  strong,  round  handle, 
was  now  struck  through  the  roof  of  the  mouth  into  the  nose,  at  the 
junction  of  the  palatine  processes  of  the  palate  and  superior  maxil- 
lary bones  (posterior  middle  palate  suture),  so  as  to  cut  forward  and 
separate  the  maxillary  bones  from  each  other  in  the  middle,  when 
the  narrow  saw  was  again  used  to  cut  through  the  root  of  the  nasal 
process  of  the  maxillary  bone,  and  strong  scissors,  curved  on  the 
flat,  made  to  cut  through  the  orbitar  palate  at  its  margin,  the  inci- 
sion being  carried  back  to  the  pterygoid  process  of  the  sphenoid, 
around  and  below  the  malar  bone. 

"  The  base  of  the  soft  palate  being  then  detached  by  a  short,  tri- 
angular knife,  curved  on  the  flat,  so  as  to  leave  the  soft  palate  at- 
tached to  the  palate-bone,  a  few  touches  of  the  knife  freed  the 
remaining  attachments. 

"  The  pterygoid  process,  malar  bone,  and  the  orbitar  plate  of  the 

*  The  figure,  by  an  error,  is  made  to  show  the  operation  on  the  right  side. 


RESECTIONS  OF  THE  MAXILLARY  BOXES.    1061 

upper  maxinary,  were  not  disturbed.  The  tumor, — which  was  scir- 
rhous,— besides  its  bony  connection,  was  also  attached  to  {he  pos- 
terior part  of  the  cheek,  and  to  the  external  pterygoid  muscle.  The 
gouge  and  scissors,  however,  sufficed  to  remove  every  part  that 
could  be  detached. 

"  The  bleeding  was  profuse,  especially  from  what  was  believed  to 
be  the  posterior  palatine  artery,  but  the  vessel  was  readily  secured 
by  means  of  a  ligature  and  Physick's  needle,  and  a  few  other  liga- 
tures, with  charpie,  arrested  the  remainder  of  the  hemorrhage." 

The  ordinary  operation  for  the  removal  of  the  superior  maxillary 
bone  may  now  be  described  in  detail.* 

If  the  disease  for  which  such  an  operation  is  to  be  performed  is  a 
tumor  of  moderate  dimensions,  say  scirrhus,  as  in  Prof.  Horner's  case, 
— which  seldom  attains  to  large  size, — the  uncovering  of  the  part  is 
to  be  effected  by  dividing  the  superior  lip  in  the  middle  line,  carrying 
the  incision  upward  along  the  base  of  the  ala  of  the  diseased  side  to 
the  inner  canthus ;  the  flap  thus  secured,  which  is  triangular,  is  dis- 
sected off  as  far  as  possible.  Now  remove  the  central  teeth,  and, 
with  a  scalpel,  make  an  incision  along  the  middle  line  of  the  hard 
palate  as  far  back  as  the  palato-maxillary  articulation  ;  at  right  angles 
with  this  incision  make  a  second,  extending  to  the  tuberosity  of  the 
maxilla,  the  cut  to  be  as  nearly  as  possible  on  the  line  of  the  articula- 
tion. Examining  at  this  stage  a  skull, — which  it  is  never  amiss  to 
have  by,-|- — take  up  a  Hey's  saw,  and  with  delicacy  and  accuracy  cut 
across  the  nasal  process,  leaving,  if  possible,  the  orbital  plate.  Next, 
with  the  same  saw,  cut  across  the  maxillo-malar  articulation;  this 
completes  the  two  upper  sections.  The  third,  the  intermaxillary,  is 
quickly  effected  by  introducing  within  the  nostril  one  blade  of  the 


*  An  arrangement  in  the  shape  of  a  double  tracheal  canuhi  has  just  been 
introduced  into  German  surgery,  and  has  received  much  encomium;  this,  of 
course,  necessitates  the  preliminary  operation  of  tracheotomy.  The  canuhi 
being  put  in  place,  the  breathing  of  the  patient  is  in  no  way  interfered  with 
by  the  hemorrhage,  thus  permitting  the  exsection  to  be  made  without  that 
haste  generally  found  so  necessary. 

f  In  a  review  of  the  first  edition  of  this  book,  "  Diseases  and  Surgery  of  the 
Mouth,  Jaws,  and  Associate  Parts,"  fault  was  found  by  the  critic  with  this 
suggestion.  To  some,  such  reminders  may  not  be  necessary  ;  the  author, 
however,  has  always  found  them  serviceable  as  immediate  hints  for  delicate 
and  accurate  manipulations.  With  a  patient  etherized,  there  can  be  no 
objection  to  the  presence  of  such  a  modeh 


1062  ORAL  DISEASES  AND  SURGERY. 

large  cutting  forceps,  the  other  being  placed  on  the  line  of  the  articu- 
lation within  the  mouth,  as  far  back  as  the  point  of  union  with  the 
palate-bone;  the  incision  is  now  made,  and  the  separation,  so  far  as 
cutting  is  concerned,  is  completed.  Take  now  a  pair  of  strong 
forceps,  and,  seizing  the  bone,  twist  it  from  its  bed. 

The  hemorrhage,  the  matter  next  demanding  attention,  varies  very 
much  with  circumstances.  It  may  be  that  twenty  arteries  will  jet 
their  blood  into  the  face  of  the  operator,  or,  on  the  contrary,  only 
two  or  three  may  require  artificial  means  for  their  control.  One 
need  not  be  either  hasty  or  timid  about  this  bleeding.  Water,  fully 
saturated  with  alum,  simply  squeezed  into  the  cavity  from  a  sponge, 
will  oftentimes  control  it.  If  this  should  not  answer  the  purpose, 
a  syringe  may  be  used,  throwing  the  water  against  the  vessels  from 
some  little  distance.  The  casting  of  a  ligature  around  a  vessel  is, 
however,  a  matter  as  easy  as  it  is  simple.  Wash  away  the  blood 
until  the  orifice  of  the  bleeding  artery  can  be  seen,  catch  it  with  the 
tenaculum,  or  forceps,  draw  it  thus  a  little  from  its  sheath,  and  tie 
it.     Repeat  this  with  each  vessel  until  all  are  secured. 

That  proper  form  and  support  may  be  given  to  the  integuments, 
the  next  step  in  the  operation  is  the  stuffing  of  the  wound.  To  do 
this,  take  a  number  of  pieces  of  old  linen,  or  patent  lint,  fold  them 
into  small  squares,  saturate  these  with  sweet  oil,  and,  one  by  one, 
pack  them  into  the  cavity  until  the  contour  of  the  part  corresponds 
with  that  of  the  other  side.  The  surgeon  must  bear  in  mind  how 
many  of  these  squares  he  has  used,  that  he  may  have  the  assurance 
at  a  future  period  that  all  have  been  removed. 

Rotundity  and  form  secured,  the  flap  is  next  laid  carefully  into 
place,  and  closely,  but  not  tightly,  approximated  by  a  sufficient  num- 
ber of  stitches  of  the  interrupted  suture.  It  is  generally  the  best 
plan  to  put  a  pin  or  stitch  first  in  the  lip,  thus  insuring  correct  ap- 
proximation at  this  most  important  point. 

As  a  dressing,  simple  cold  water,  if  deemed  necessary,  may  be 
used,  keeping  the  parts  constantly  cool  by  its  continuous  renewal  ; 
or,  if  water  alone  is  found  insufficient  to  control  vascular  excitement, 
it  may  be  medicated  with  lead  in  the  proportion  of  SU  to  ^xvj. 
Cold  water,  however,  will  generally  be  found  sufficient. 

Concerning  the  pads  or  squares  inside,  it  will  be  found  the  best 
practice  not  to  allow  them  to  dry  from  the  time  of  their  first  intro- 
duction. This  is  to  be  prevented  by  the  repeated  dropping  among 
the  pads  of  drops  of  oil  from  a  tubed  vessel. 

The  stitches  used  in  approximating  the  external  wound  are  to  be 


RESECTIONS  OF  THE  MAXILLARY  BONES.    1063 

removed  as  soon  as  possible :  three  or  four  days  will  generally  allow 
of  such  removal.  It  is  well  to  remove  them  gradually,  taking  away 
intermediate  ones. 

The  withdrawal  of  the  squares  is  to  be  effected  leisurely:  indeed, 
the  principle  is  to  consider  them  as  a  tent,  to  be  thrown  out  as  the 
wound  granulates  and  fills  up  below  them  ;  pick  out  the  top  or  middle 
ones,  as  the  irritation  produced  by  their  over-retention  compels  vou. 
Or,  if  it  seem  necessary,  after  the  first  three  days  have  passed,  they 
may  all  be  removed,  and  renewed,  in  lessening  numbers,  daily. 

This  completes  the  surgical  proceedings  of  such  a  resection. 

Many  cases,  however,  occur  where  the  external  incision  here  sug- 
gested might  not  be  the  best  one,  and,  indeed,  where  it  might  not 
be  sufficient  to  uncover  the  disease.  Certain  surgeons  prefer  to  ex- 
pose the  bone  by  an  incision,  commencing  at  the  angle  of  the  mouth, 
and  passing  obliquely  in  front  of  the  Stenonian  duct  to  the  centre 
of  the  malar  bone,  throwing  thus  the  flap  upward  and  inward  from 
below.  Another  mode  is  to  use  both  these  incisions  upon  the  same 
subject,  a  necessary  proceeding,  in  many  cases,  where  the  tumor  is 
large. 

"Mr.  Fergusson,  who  is  particularly  successful  in  oral  surgery, 
in  remarks  after  an  operation  for  the  removal  of  disease  affecting  the 
alveolus  and  antrum,  made  some  important  and  interesting  observa- 
tions, having  reference  generally  to  the  exposure  of  such  parts  prior 
to  the  removal  of  the  actual  disease.  He  said  that  formerly,  and 
even  now,  some  surgeons  were  in  the  habit  of  freely  dividing  the 
integument  of  the  cheek,  lip,  etc.,  trying  to  get  at  the  disease  from 
various  points:  that  one  method  he  pursued  with  advantage  (as  in 
a  case  of  removal  of  malignant  disease  of  the  upper  jaw)  was  to 
divide  the  upper  lip  in  the  median  line,  and  then  by  carrying  the 
incision  on  one  or  both  sides,  as  the  circumstances  of  the  case  re- 
quired it,  into  the  nose,  to  dissect  back  the  upper  lip,  ala  nasi,  and 
cheek,  and  thus  expose  the  parts  freely,  avoid  the  deformity  of  scar 
on  the  cheek,  or,  to  use  his  own  words,  '  to  leave  as  few  marks  of 
the  surgeon's  doings  on  the  face  as  possible.'  In  a  case  before  him 
at  the  time  the  remarks  were  made, — a  young  woman, — he  was  al)le 
to  remove  the  disease  without  interfering  with  the  lip.  It  atfectcd 
the  alveolar  ridge  of  the  right  side,  extending  from  the  second  incisor 
to  the  second  molar,  and  was  continued  into  the  antrum  ;  but  whether 
it  first  arose  in  the  antrum  or  the  alveolus,  he  did  not  know.  Mr. 
Fergusson  attributed  the  success  attending  this  method  of  removal, 
in  a  great  measure,  to  the  instrument  he  used,  viz.,  a  pair  of  clipping 


100^  ORAL  DISEASES  AND  SURGERY. 

forceps.  He  first  clipped  away  the  alveolar  ridge,  and  then  attacked 
the  portion  of  disease  situated  in  the  neighborhood  ;  by  this  means 
freely  laying  open  the  antrum  and  nostril.  He  alluded  to  a  case  in 
which  Mr.  Bowman  successfully  removed  a  large  tumor  from  the 
antrum  extending  into  the  mouth,  without  dividing  the  lips." 

Such  a  mode  of  uncovering  a  tumor  of  limited  size  is  admirable: 
the  section  will  be  found  to  make  a  large  exposure,  but  the  scar  left 
will  scarcely  be  remarked. 

Operation  for  IIesection  of  botei  Superior  Maxillje. — It  has 
never  fallen  to  the  lot  of  the  author  to  resect,  or  to  see  resected, 
both  maxillary  bones.  Several  such  operations  are,  however,  on 
record  ;  and  from  them  may  be  selected  that  of  Heyfelder,  as  being 
the  one  most  practicable  and  ea.sy  of  accomplishment. 

The  patient  is  to  be  seated  in  a  chair,  with  bis  bead  supported  by 
an  assistant,  or,  better,  he  may  lie  down.  An  incision  is  made  on 
each  side  of  the  face,  from  the  external  angle  of  the  eye  to  the  labial 
commissure ;  the  included  parts  are  now  reflected  upward  toward 
tlie  forehead  until  the  infra-orbital  ridges  are  exposed.  This  uncovers 
the  whole  of  both  bones.  The  chain  saw  is  now  passed  through  the 
spheno-maxillary  fissures,  the  malar  bones  are  divided,  the  maxillae 
separated  from  the  ossa  nasi,  and  the  vomer  and  thinner  bones  are 
cut  with  strong  scissors.  These  steps  complete  the  separation,  when 
the  bones  are  to  be  pried  from  the  cavities  with  elevators  or  twisted 
away  with  the  lion  forceps  of  Liston.  The  result  of  an  operation 
thus  performed  by  the  deviser  himself  is  described  as  follows:  "  Very 
little  blood  was  lost,  torsion  and  compression  sufiicing  to  arrest  the 
hemorrhage.  Two  hours  afterward,  the  edges  of  the  wound,  from  the 
angles  of  the  eyes  to  the  corners  of  the  mouth,  were  united  by  twenty- 
six  stitches  of  the  interrupted  suture ;  cold  lotions  were  applied  :  there 
was  no  reaction  or  swelling,  and  the  patient  could  swallow  water 
and  broth.  Four  days  subsequently,  the  wound  had  nearly  healed 
by  the  first  intention,  and  in  six  weeks  the  patient  was  exhibited  to 
the  Medical  Society  of  Erlachen.  At  this  time  there  was  no  deformity 
of  the  features  :  a  fissure,  thirteen  lines  long  and  three  wide,  was  seen 
along  the  median  line  of  his  mouth ;  the  soft  palate  and  uvula  were 
in  their  natural  place  ;  deglutition  was  free;  the  nose  had  assumed 
its  original  form  and  direction.  And  the  face,  which,  before  the 
operation,  was  like  that  of  a  monkey,  again  possessed  a  human 
expression  ;  a  firm  and  solid  tissue  replaced  the  extirpated  parts." 

Resections  of  the  Inferior  Maxilla — in  whole  and  in  part. 
— Partial  resections  of  the  lower  jaw  have  become  so  common  as  to 


* 


EESECTIONS   OF  THE  MAXILLARY  BOXES.    1065 

elicit  little  attention.  The  author  has  himself  made  such  sections 
in  not  less  than  a  hundred  cases.  The  causes  necessitating  such 
operations  are  considered  in  other  parts  of  this  work.  (See  chapters 
on  Tumors.) 

Subfigures  6,  T,  and  8,  Plate  XVII.,  exhibit  various  steps  in  such 
resection,  and  are  photographically  true,  allowing  for  the  absence  of 
the  blood. 

For  the  removal  of  a  class  of  tumors  having  origin  back  of  the 
superior  maxilla,  Langenbeck  has  proposed  what  he  terms  the  osteo- 
plastic resection  of  the  jaw.  This  operation  consists  in  detaching 
the  jaw  from  its  relations,  except  at  one  side,  and  then  forcing  it  in 
the  direction  of  the  attached  part, — that  is,  turning  it  out  of  place. 
He  removes  the  tumor,  and,  after  controlling  the  hemorrhage,  re- 
places the  bone. 

Where,  in  this  operation,  may  be  the  related  part,  is  somewhat  a 
matter  for  the  preference  of  the  operator,  or  otherwise  is  directed 
by  the  peculiarities  of  special  cases.  Langenbeck  himself,  after  ex- 
posing the  bone,  as  in  the  ordinary  operation,  passes  the  saw  through 
the  maxillo-malar  articulation,  along  the  orbital  angle,  and  then 
without  further  section,  if  possible,  turns  the  bone  toward  the  mesiau 
aspect:  if  this  may  not  be  done,  he  then  makes  section  of  the  palatine 
raphe.  As  a  modification  of  this  operation,  Dr.  Cheever,  a  Boston 
surgeon,  separates  the  nasal  and  malar  attachments,  leaving  in  rela- 
tion the  palatine,  thus  throwing  the  bone  downward. 

In  the  removal  of  large  and  threatening  nasal  and  naso-pharyngeal 
polypi,  osteoplastic  operations  of  the  most  severe  character  find 
commendation  in  the  greater  risk  they  are  designed  to  avoid. 

A  mode  of  getting  at  these  tumors,  when  they  spring  from  the 
spheno-occipital  base,  and  one  which,  on  a  single  occasion,  was  prac- 
ticed with  most  satisfactory  results  by  the  author,  consists  in  splitting 
the  soft  palate,  and  by  a  ligature  passed  through  the  apex  of  either 
flap  drawing  the  veil  aside. 

Still  another  mode,  one  practiced  by  Oilier,  applying  more  par- 
ticularly where  tumors  are  situated  well  back  in  the  nares,  consists 
in  making  a  U-iucision  over  the  bridge  and  along  the  sides  of  the 
nose,  having  the  apex  looking  toward  the  forehead ;  the  flap,  which 
is  the  nose,  is  now  turned  downward.  Should  space  enough  for  the 
manipulation  needed  be  not  thus  obtained,  Oilier  uncovers  by  a 
second  incision  the  maxillae,  and  saws  away  such  portions  of  the 
bones  as  may  be  found  necessary. 


1066 


ORAL  DISEASES  AND  SURGE  BY. 


Complete  section  of  the  lower  jaw  is  one  of  the  most  disfiguring 
and  comfort-destroying  operations  that  can  be  practiced  on  the  living 
being,  and  is  nev^er  to  be  performed  without  the  existence  of  a  well- 

FiQ.  351. — Mouth-Stretchee  Applied. 


recognized  or  proven  necessity.  Any  section  of  the  alveolar  process 
may  generally  be  easily  accomplished  without  external  wound,  the 
lips  being  held  out  of  the  way  by  the  mouth-stretcher  used  in  the 
performance  of  dental  operations. 


Fio.  352. 


A  second  form  of  mouth-stretcher,  or  lip-holder,  one  devised  by 
Dr.  Goodwillie,  is  shown  in  Fig.  352.    This  instrument  takes  up  less 


RESECTIONS   OF  THE  3IAXILLARY  BONES.    1067 

room,  and  on  that  account  may,  in  many  cases,  have  preference  over 
the  former. 

In  cases  where  section  of  the  lip  may  be  thought  desirable,  as 
when  the  practitioner,  from  inexperience,  may  not  be  able  to  accom- 
plish the  removal  without  such  exposure,  various  cuts  are  proposed. 
These  cuts  may  be  fully  understood  by  the  studies  presented.  Sub- 
figure  8,  Plate  XVII.,  represents  exposure  of  the  mental  portion  of 
the  bone.  The  flaps,  1,  2,  are  made  by  a  single  vertical  incision 
through  the  median  line  of  the  lower  lip,  crossed  by  a  second  at  right 
angles  at  the  base  of  the  jaw,  extending  on  either  side,  laterally,  as 
far  as  the  bone  is  required  to  be  removed. 

Subfigure  T  represents  the  exposure  of  the  whole  left  half  of  the 
jaw.  To  accomplish  this,  make  a  first  incision  in  the  median  line 
to  the  under  border  of  the  bone.  From  this  carry  a  second  under 
the  jaw — although  along  it — to  the  temporo-maxillary  articulation. 
Dissect  now  the  flap  upward.  In  the  horizontal  cut  here  made  it 
will  be  perceived  that  the  facial  artery  is  divided ;  this  is  a  large 
vessel,  and  requires  a  ligature.  It  will  be  found  the  better  practice 
to  tie  both  ends  before  proceeding  to  the  operation  upon  the  bone. 
The  coronary  artery,  cut  in  the  vertical  incision,  will  often  compel  a 
ligature. 

Subfigure  6  exhibits  an  exposure  of  the  whole  body  of  the  bone. 
This  is  accomplished,  as  seen  in  the  drawing,  by  a  simple  horizontal 
incision  along  the  base  of  the  jaw,  being  carried  from  angle  to  angle, 
and  the  flap,  including  the  mouth  entire,  thrown  up ;  or  it  may  be 
secured  by  joining  the  horizontal  to  a  vertical  incision  made  from 
the  angle  of  the  mouth ;  or,  as  in  Fig.  8,  by  the  median,  vertical, 
and  horizontal  incisions.  These  sections  understood,  any  required 
modification  will  suggest  itself. 

Subfigures  4,  5,  6,  represent  an  operation  practiced  by  Dr.  J. 
Rhea  Barton :  4  exhibits  the  tumor,  which  will  be  seen  to  be  of 
great  bulk,  being  described  as  having  complete  possession  of  the 
mouth,  forcing  the  tongue  into  the  pharynx,  and  stretching  the  jaws 
widely  apart.  It  also  rose  up  outside  the  superior  maxillary  bone, 
protruding  the  lips,  cheek,  and  neck  on  the  left  side. 

Finding,  by  examination,  that  the  base  of  the  bone  might  be  left 
with  promise,  Dr.  Barton  made  the  resection  as  exhibited  by  the 
lines  in  5.  This  was  accomplished  by  sawing  horizontally  from 
without  inward,  commencing  at  the  middle  line  below  the  canal, 
and  extending  the  section  bilaterally.  The  removal  of  the  bone,  in 
this  particular  operation,  gave  no  hemorrhage  requiring  attention. 


1068  ORAL  DISEASES  AND  SURGERY. 

The  flaps  being  replaced  and  stitched,  the  patient  was  well  in  a 
month. 

Complete  section  of  the  jaw,  as  exhibited  in  Fig.  8,  after  the  prac- 
tice of  Dupuytren  and  many  successors,  destroys  forever  the  articu- 
lation of  the  jaws,  and  interferes  not  only  with  mastication,  but  seri- 
ously with  deglutition  and  speech.  Exposing  the  bone  as  directed, 
the  section  is  most  easily  made  with  either  the  Hey,  metacarpal,  or 
chain  saw.  Before,  however,  shaving  from  the  bone  its  inner  attach- 
ments, a  loop  of  waxed  silk,  or  silver  wire,  is  to  be  passed  through 
the  tip  of  the  tongue,  that  thus  this  organ  may  be  prevented  from 
being  drawn  back  into  the  pharynx  by  the  genio-hyoid  and  stylo-hyoid 
muscles. 

Subfigure  7  exhibits  the  removal  of  one-half  the  maxilla.  Ex- 
posing the  bone  as  directed,  remove  one  or  more  of  the  centre  teeth ; 
next,  from  without  inward,  saw  through  the  bone,  or,  if  preferred, 
use  a  chain  saw,  carrying  it  around  the  bone  by  the  aid  of  a  curved 
needle.  Catching  now  the  bone  in  the  grasp  of  the  forceps,  or  using 
the  fingers,  as  preferred,  detach  the  inner  soft  parts,  twisting  the 
bone  outward  and  downward.  Arriving,  in  the  dissection,  at  the 
coronoid  process,  the  temporal  tendon  is  to  be  detached  by  a  chisel- 
shaped  knife,  care  being  taken  not  to  wound  the  maxillary  artery  or 
internal  carotid.  This  process  freed,  the  condyle  can  be  twisted 
from  its  ligaments,  or,  better  still,  twisted  and  at  the  same  time  cut 
away.  This  operation,  apparently  se  formidable,  the  author  has 
succeeded  in  doing  without  external  incision.  "With  the  section  of 
the  soft  parts,  as  represented  in  the  figure,  it  is  not  nearly  so  difl&cult 
as  might  be  supposed.  A  diseased  bone  is  seldom  so  difficult  to 
disarticulate  as  a  sound  one. 

Prof.  Smith,  in  his  System  of  Surgery,  gives  the  credit  to  Dr.  Geo. 
McClellan  of  having  been  the  first  to  attempt  more  than  a  limited 
section  of  this  bone, — this  surgeon,  in  1823,  having  removed  all  the 
parts  anterior  to  the  angles.  In  this,  however,  he  was  preceded  by 
Deadrick,  of  Tennessee,  who,  in  1812,  made  a  resection  which  ex- 
tended from  the  symphysis  to  the  angle.  Prof.  Mott,  of  New  York, 
is  also  referred  to  as  having  made  an  operation  similar  to  Deadrick's, 
in  1821.  Dr.  Ackley,  of  Cleveland,  Ohio,  is  reported  as  having,  in 
1850,  removed  the  bone  entire.  In  Europe,  priority  of  the  operation 
performed  first  by  Deadrick  is  awarded  to  Dupuytren.  Mott,  ac- 
cording to  Prof.  Smith,  disarticulated  the  bone, — Deadrick  and  Du- 
puytren did  not.  Prof.,  Mott  thought  it  necessary  to  ligate  the 
primitive  carotid  artery  a  few  days  before  making  his  resection,  a 


RESECTIONS   OF   THE  MAXILLABT  BONES    1069 

step  long  since  proved  to  be  entirely  uncalled  for,  complicating  and 
increasing  the  dangers  of  the  operation. 

The  performance  of  Dr.  Deadrick,  deservedly  famous  for  its  pri- 
ority, was  done  on  the  person  of  a  lad  fourteen  years  of  age.  The 
operation  was  for  the  removal  of  a  cartilaginous  tumor  on  the  left  side 
of  the  jaw,  which  filled  up  nearly  the  whole  of  the  mouth,  causing  the 
greatest  diflSculty  in  swallowing,  and,  at  times,  even  in  breathing.  To 
accomplish  his  resection,  Dr.  Deadrick  commenced  an  incision  under 
the  zygomatic  process,  and  carried  it  across  the  tumor,  downward 
and  forward,  to  nearly  an  inch  beyond  the  middle  of  the  chin.  From 
the  centre  of  this  first  incision,  and'  consequently  at  right  angles  with 
it,  an  incision  was  extended  a  short  distance  upon  the  neck;  the 
flaps  thus  secured  were  dissected  from  the  diseased  mass,  and  the 
bone  next  sawed  off  at  the  angle  and  symphysis.  The  flaps  were 
laid  back  in  the  usual  way,  the  boy  making  a  speedy  recovery. 

Nerve  Section. — A  most  interesting  department  of  resective  sur- 
gery— for  it  may  be  thus  termed — is  found  in  the  operations  required 
to  expose  nerves  involved  in  neuralgic  lesions.  It  is  certainly  no 
longer  a  question  that  sections  of  nerve-cords  may  be  made  without 
special  danger  or  risk, — the  greater  question  being  always  the  estab- 
lishment of  a  correct  diagnosis.  In  the  chapter  on  Neuralgia  occa- 
sion was  taken  to  remark  that  such  operations  were  far  from  being 
satisfactory;  but  that  remark  is  here  to  be  modified  by  pronouncing 
the  fault,  in  many  of  the  cases,  to  be  rather  with  the  surgeon  than 
with  his  case.  Section  of  a  nerve  is  only  justified  where  on  the  peri- 
pheral side  there  exists  a  lesion  which  may  not  otherwise  be  cured ; 
and  of  such  cases  there  are,  without  doubt,  many. 

Section  of  Inferior  Maxillary  Nerve. — While  it  cannot  be 
denied  that  many  of  the  reported  cases  of  section  of  the  inferior 
maxillary  nerve  have  been  made  without  necessity,  yet  it  is  certainly 
an  operation  to  be  practiced  and  commended. 

Reference  to  Fig.  353  will  show  that  the  nerve,  which  is  a  cord  of 
some  size,  passes  within  the  substance  of  the  jaw  midway  to  the  thick- 
ness, and  on  a  line  which  would  be  well  enough  marked  by  taking 
the  centre  between  the  base  of  the  bone  and  the  cutting  edges  of  the 
teeth.  Approaching  the  ramus,  it  ascends  obliquely  upward  and  back- 
ward, escaping  operative  proceeding  at  the  posterior  dental  foramen. 

To  expose  this  nerve,  if  within  the  ramus,  begin  an  incision  at 
the  sigmoid  notch,  and  carry  it  downward  through  the  integu- 
ments,, carefully  avoiding  the  wounding  of  any  overlying  part  of  the 


1070 


ORAL  DISEASES  AND  SURGERY. 


parotid  gland ;  the  gland  discovered,  push  it  carefully  backward, 
and  complete  the  incision  down  to  the  bone,  scraping  aside,  rather 
than  removing,  the  periosteum.      Still  another  mode,  and  the  one 


Fig.  353. 


most  commonly  practiced,  is  an  incision  made  as  exhibited  in  Fig. 
354,  inclining,  however,  the  base  of  the  flap  more  forward  than  is 
shown  in  the  diagram.  As  the  next  step,  after  the  exposure  is  made, 
take  a  small  trephine,  and  cut  out  two  sections,  or  rather  cut,  with 
the  trephine,  sufficiently  deep  to  reach,  or  very  nearly  reach,  the 
nerve-canal.  Take  now  the  chisel,  and  with  gentle  cuts  remove  the 
intervening  portion  of  bone.  If  the  operation  be  carefully  performed, 
the  nerve  can  be  uncovered  without  being  wounded.  Reaching 
the  vessels,  isolate  the  nerve  from  the  artery  and  vein  by  lifting  it 
upon  the  tenaculum.  It  is  now  to  be  divided,  removing  as  much  as 
is  thought  desirable,  never  less  than  half  an  inch,  and  if  more,  cer- 
tainly the  better. 


RESECTIONS  OF  THE  MAXILLARY  BONES.    1071 


If  the  operation  is  to  be  performed  within  the  body  proper  of  the 
bone,  the  uncovering  is  even  more  simple  :  use  the  straight  or  curved 
line,  cutting  midway  upon  the  bone,  separate  the  lips  of  the  wound 
by  delicate  retractors,  securing 

thus  a  free  exposure  (with  the  Fio-  354. 

periosteum  scraped  away,  as  be- 
fore suggested),  trephine,  and 
remove  the  section. 

The  facial  artery,  it  is  not 
to  be  forgotten,  passes  in  front 
of  the  masseter  muscle;  if  this 
is  necessarily  cut,  the  operator 
must  stop  and  throw  a  ligature 
about  it:  it  is  better  to  tie  both 
ends.  Cuts  into  the  muscular 
substance  are  to  be  avoided  as 
much  as  possible;  such  incisions 
add  to  the  trouble  of  an  opera- 
tion by  the  free  hemorrhage 
provoked. 

A  section  of  the  nerve-cord  secured,  the  surgeon  carefully  lays 
back  the  flaps  and  watches  the  result.  It  has  been  thought  well  by 
some  to  give  large  doses  of  an  opiate  immediately  after  such  opera- 
tions; but  when  this  is  required,  unless  opiates  have  been  made  a 
necessity  from  abuse  of  the  means,  I  think  the  operation  will  be 
found  to  prove  a  mistake,  as  in  such  successful  cases  as  have  occurred 
in  my  own  experience,  the  relief  from  suffering  experienced  has  acted 
as  the  profoundest  of  opiates, — the  patients  sleeping  for  the  first  few 
days  almost  continually. 

Where,  on  the  contrary,  a  patient  has  long  habituated  himself  to 
the  use  of  opiates,  a  continuation  will  be  found  as  much  a  necessity 
as  is  stimulation  in  delirium  tremens:  here,  indeed,  the  neuralgia 
corresponds  with  Dr.  Anstie's  view  that  it  is  a  condition  of  depres- 
sion. 

To  cure  a  patient  of  the  necessity  for  the  stimulation  of  opium  is 
not  unfrequently  found  a  more  difficult  task  than  was  the  true  treat- 
ment of  the  original  cause  of  the  pain. 

Superior  Maxillary  Nerve.— Section  of  the  branches  of  the 
superior  maxillary  nerve  is  practiced  with  a  difficulty  corresponding 
to  the  requirements  of  the  various  cases.     The  case  of  a  Mrs.  B., 


1072  ORAL  DISEASES  AND  SURGERY. 

recorded  on  page  TIT,  affords  an  example  of  an  easy  manner  of 
cutting  those  branchlets  which  cross  the  antrum  from  the  intra- 
orbital foramen.  Branches  known  as  the  infra-orbital — that  is,  those 
which,  bush-like,  expand  from  the  infra-orbital  foramen — are  easy  of 
a  common  division  through  a  trap-door-like  flap  made  upon  the  cheek 
over  the  position  of  that  foramen. 

Cases,  however,  occur,  where  pain  is  so  diffused  over  the  track  bf 
the  second  division  of  the  fifth  nerve,  and  where  the  suffering  of  the 
patient  is  so  intolerable,  as  absolutely  to  force  the  surgeon  into  oper- 
ation even  in  the  absence  of  a  perfectly  reliable  diagnosis,  and  when 
it  is  felt  that  no  section  outside  of  the  main  branch  may  promise 
any  good.  In  these  instances,  the  results  too  frequently  prove  the 
worse  than  empiricism  of  the  practice ;  too  often  does  continuous 
pain,  transferred  to  some  other  part,  show  that  the  lesion  is  still 
back  of  the  seat  of  operation.  The  author  does  not,  however,  con- 
demn these  operations:  desperate  evils  call  for  desperate  ren)edies. 
He  would  only  enjoin  that  it  be  well  understood  that  a  desperate 
remedy  must  not  be  uselessly  or  unnecessarily  employed,  and  that 
no  man  should  undertake  the  resection  of  the  superior  maxillary 
nerve  until  he  is  assured  that  he  has  mastered  all  that  can  be  known 
of  the  case.  The  chapters  in  this  book  on  Neuralgia  and  Odontalgia 
will  be  found  full  of  hints,  experiences,  and  suggestions  in  this  direc- 
tion, iind  may  be  referred  to  with  benefit. 

The  exposure  of  the  second  branch  of  the  fifth  nerve  was  first 
practiced  in  this  country  by  Dr.  Carnochan,  of  New  York,  and  the 
plan  originally  adopted  l)y  this  surgeon  for  the  exposure  is  tlie  same, 
with  unimportant  modifications,  as  that  still  practiced. 

Commencing  this  operation,  a  Y-shaped  or  simple  curvilinear 
flap  exposes  the  anterior  wall  of  the  antrum.  A  trephine,  as  large 
as  may  be  used,  is  now  made  to  remove  this  wall.  The  posterior 
wall  thus  exposed,  a  second  trephine,  necessarily  somewhat  smaller 
than  the  first,  removes  a  section  of  this;  the  spheno-maxillary  fossa 
thus  exposed,  the  nerve  is  found  and  isolated  from  its  surroundings 
and  as  much  of  it  removed  as  may  conveniently  be  effected.  If,  in 
the  opening  made  through  the  antrum,  space  enough  has  not  been 
secured  by  the  trephine,  the  operator  will  find  himself  compelled  to 
remove,  by  means  of  chisels  and  cutting  pliers,  the  lower  boundary 
of  the  infra-orbital  canal ;  this  will  be  found  to  enlarge  the  working 
space  considerably. 

In  seeking  in  the  fossa  for  the  nerve,  too  much  delicac}'^  cannot  be 
exercised,  as  above  all  things  is  it  desirable  to  have,  if  possible,  a 


RESECTIONS   OF   THE  MAXILLARY  BOXES.     1073 

healing  of  the  parts  without  degeneration  or  destruction  of  the 
tissues. 

A  mode  of  exposing  the  antral  wall,  affording  greater  convenience 
in  the  succeeding  steps  of  the  operation,  consists  in  dividing  the  lip 
and  cheek  by  an  incision  leading  directly  from  the  labial  commissure 
to  the  malar  bone:  two  flaps  are  thus  created,  one  being  directed 
inward,  the  other  outward. 

An  operation  devised  by  Langenbeck  for  section  of  this  nerve, 
being,  however,  one  that  is  scarcely  likely  to  meet  with  much  favor, 
consists  in  the  use  of  a  stout  tenotome,  which  is  to  be  thrust,  with 
its  point  directed  downward  and  backward,  immediately  beneath  the 
external  palpebral  ligament,  being  kept  in  close  contact  with  the 
outer  wall  of  the  orbit  until  it  reaches  the  spheno-maxillary  fissure, 
this  being  recognized  in  the  cessation  of  resistance.  The  edge  of  the 
knife  is  now  turned  so  as  to  shave  the  surface  of  the  bone,  the 
nerve  being  cut  by  a  sawing  motion  as  it  enters  the  orbital  canal. 
A  cut  opening  the  canal  is  now  to  be  made  through  the  floor  of  the 
orbit,  and  with  a  hook  the  nerve  is  to  be  caught  and  pulled  from  its 
bed. 

Pancoast's  operation  for  exposure  of  the  second  and  third  branches 
of  the  trifacial  is  performed  as  follows  :  First,  as  exhibited  in  Fig. 
354,  a  trap-like  flap  is  made  across  the  ramus  of  tlie  lower  jaw. 
This  being  raised  and  reflected,  the  masseter  muscle  is  shaved  from 
its  attachment,  and  the  coronoid  process  exposed;  this  process  is 
next  sawed  off  at  its  root,  and,  having  detached  from  it  the  temporal 
muscle,  is  removed  ;  the  muscles  being  thrust  upward  out  of  the 
way.  This  series  of  manipulations  exposes  the  spheno-maxillary 
fissure,  across  which,  but  overlaid  with  some  fatty  tissue,  passes 
the  internal  maxillary  artery,  which  a  succeeding  step  picks  out  and 
ligates.  The  next  use  of  the  knife  is  found  in  detaching  from  the 
great  ala  of  the  sphenoid  bone  the  external  head  of  the  pterygoid 
muscle  ;  this  accomplished,  any  soft  parts  found  in  the  way  are  to 
be  pushed  aside  with  the  finger,  after  which  attention  is  to  be  given 
to  staunching  the  hemorrhage  and  oozing. 

The  parts  thus  exposed  and  dried,  the  nerves  of  the  zygomatic 
fossa  are  plainly  visible,  and  may  be  exsected  by  using  a  pair  of 
curved  scissors. 

Exposure  of  the  second  branch  after  this  manner  of  operation  is 
a  complicated  matter.  From  the  point  gained,  an  incision  is  to  be 
carried  upwards  and  inwards  to  the  spheno-maxillary  fossa  as  far  as 
the  external  rectus  muscle.     By  means  of  a  hook  carrying  a  well- 

^67 


1074  ORAL  DISEASES  AND  SURGERV. 

waxed  thread,  the  nerve  is  now  to  be  encircled  and  so  controlled  as 
to  allow  of  section  being  made  with  the  knife;  all  that  portion  being 
removed  which  lies  between  the  foramen  behind  and  the  bones  in 
front, — about  the  third  of  au  incli. 

Inversion  and  Eversion  of  the  Lip. — It  sometimes  happens 
that,  from  accident  or  congenital  defect,  the  lip — generally  the  lower — 
is  inverted  or  everted.  AVhen  turned  inward,  the  part  is  shortened, 
and  not  unfrequently  permits  the  escape  of  the  oral  fluids.  Inver- 
sion, while  generally  tiie  result  of  some  cancroid  adection  which 
Las  produced  considerable  cicatricial  tissue,  is  yet  occasionally  ob- 
served associated  with  some  perversion  of  the  fraenum,  this  fold  being 
unduly  short,  or  running  too  near  the  free  ed<^o  of  the  lip.  A  case  of 
inversion,  the  worst  the  author  has  ever  met,  resulted  from  a  gun-shot 
wound,  involving  both  lip  and  jaw.  In  this  case  that  surface  which 
was  the  free  edge  liad  become  involved  in  the  reparative  uuitcrial 
near  the  base  of  the  alveolar  j)rocess,  and  had  thus  become  tightly 
bound  to  these  parts;  the  teetl),  and  face  of  the  gums,  being  exposed. 
To  prevent  the  dril>bliugs  from  his  mouth  passing  to  the  neck  and 
breast,  the  patient  had  constructed  for  himself  a  species  of  tin  cup, 
which  he  constantly  wore  bound  to  his  chin,  and  whicii  was  con- 
cealed from  observation  by  a  large  neckerchief. 

Eversion,  the  more  common  condition,  depends,  like  inversion,  on 
a  variety  of  causes.  A  burn  received  about  the  chin,  contracting 
the  part,  has  frequently  produced  it.  Hypertrophy  of  the  mucous 
membrane  is  an  occasional  cause;  preternatural  elongation  of  the 
frffiiium  permits  such  falling  outward.  Any  loss  of  substance  exter- 
nally, contracting  the  parts,  necessarily  tends  to  eversion. 

Treatment  of  inversion  or  eversion  varies,  of  course,  with  the 
various  causes.  In  the  inversion  of  the  lip  where  such  cause  lies  in 
the  existence  of  cicatricial  tissue,  it  will  be  found  easier  to  devise 
than  to  secure  the  nutans  of  cure.  If  the  lip  has  length,  operation 
may  be  attempted  Ijy  an  elliptical  portion  taken  from  the  outer  surface, 
the  parts  being  brought  together  and  an  immediate  union  secured 
through  the  use  of  the  hare-lip  pin  or  common  interrupted  suture  ; 
if,  on  the  contrary,  the  lip  has  been  shortened  in  its  bulk,  as  is  fre- 
quently the  case  where  the  ulcer  has  Ijeen  deep,  we  must  depend 
for  relief  on  a  plastic  oi)eration :  such  an  operation  consists  in  cut- 
ting away  the  cicatrix  and  transplanting  a  pedicled  flap,  to  be  made 
as  directed  in  the  chapter  on  Autoplasty. 

A  shortened  or  improperly  attached  fraenum  is,  generally,  most 


RESECTIONS   OF  THE  MAXILLARY  BOXES.     1075 

easy  of  correction, — a  section,  more  or  less  extensive,  assisted  bv  a 
frequent  turning  outward  of  tlie  parts  by  the  patient,  quicldy  result- 
ing in  the  cure. 

Inversion  from  gun-shot  injuries  classifies  itself  with  contraction 
from  ulceration  ;  each  case  is  a  study  in  itself,  and  will  be  found  to 
have  its  own  peculiar  demands.  Many  of  these  conditions  have  no 
cure,  the  patient  being  doomed  to  drag  through  an  undesirable  ex- 
istence. Others  will  be  found  very  easy  of  remedy,  some  attached 
point  requiring,  perhaps,  alone  to  be  freed.  An  intermediate  class, 
and  this  is  by  far  the  most  common,  demands  a  combination  of  ope- 
rations,— such  requirements  suggesting  themselves  to  the  ingenious 
surgeon. 

E versions  are  treated  on  the  same  general  principles.  An  ellipsis 
from  the  mucous  face  of  the  lip  is  the  most  common  mode  of  cure 
resorted  to.  A  second  mode  is  a  double  Y-shaped  incision,  the  centre 
of  the  cut  being  the  centre  of  the  lip ;  the  space  within,  being  wider 
than  that  without,  naturally  draws  the  parts  inward  and  downward. 
In  preternatural  elongation  of  the  frgenum  I  have  secured  satisfac- 
tory results  by  cutting  out  a  limited  portion  of  the  bridle  and  pro- 
ducing an  eschar  by  the  use  of  nitrate  of  silver.  Or,  if  the  operator 
prefer,  he  may  stitch  the  parts  together  after  the  abbreviation,  se- 
curing the  continuance  of  the  approximation  by  the  use  of  a  turn  or 
two  of  a  bandage. 


I N  D  E  X. 


Abbott's  pluggers 341 

Abrasion  of  cutting  face  of  teeth  506 

treatment  of 506 

Abscess  associated  with  wisdom 

teeth 174 

dental 34 

of  antrum 665 

of  tongue 783 

of  tonsil  gland 528 

Absorption  of  alveoli 382 

of  gums 382 

Accidents  in  root  filling 388 

in  tooth  extraction 423 

Acid  secretions 257 

Acids   in   treatment    of    dental 

»    caries 255 

Acne 189 

Action  of  ether  on  nerve  centres.  437 

Acupressure  in  hemorrhage 599 

Acupuncture  in  trismus 199 

Acute  glossitis 778 

periodontitis 149 

synovitis 183 

Adenoid  tumors 936 

Adenoma 815 

Adhesion  of  the  gums 547 

Adhesive  gold  fillings 307 

gold  foil 307 

Administration  of  ether 433 

Adventitious  tongue-tie 802 

Adynamic    inflammation    from 

dental  irritation 116 

Age,  relation  of,  to  use  of  chloro- 
form   499 

Agents  in  contact  with  the  teeth  254 

Agnew,  Prof.  D.  H.,  on  hare-lip  954 

on  ranula 755 

Agnew's  suture  for  hare-lip 958 

Allport's    operation    on    dental 

pulp 393 

Alteratives  in  tetanus 190 

Alum  in  hemorrhage 115 

Aluminium  for  obturators 1051 

Alveolar  abscess 170 

necrosis 572 

process 31,  100 

round-celled  sarcoma 880 

Alveoli 104 


Amalgam 284 

Amputation  of  tonsil  glands 523 

instruments  used  in 523 

of  uvula 528 

Anaesthesia,  generah., 431 

local..    427 

by  chloroform 441 

by  ether 432 

Analysis  of  eggs 238 

of  Indian  corn 247 

of  milk 237 

of  mutton  fat 238 

of  oats 243 

o^  potatoes 242 

of  saliva 277,  495 

of  starch 238 

of  sugar 238 

of  teeth 233,  234 

of  wheat 238,  245 

Anatomy  of  face 29 

of  soft  palate 66,  1015 

of  superior  maxilla 33 

Anchylosis  of  jaw 182 

Angina  aphthosa 119 

chronic 121 

treatment  of 122,  123 

simplex 119 

diet  in 120 

treatment  of 120 

Angionoma..  815,  937' 

Annealing  gold  foil 327 

Anomalies  in  abscess 172 

in  dentition 141 

in  situation  of  calculi 497,  501 

Anterior  palatine  canal 37 

pillar  of  fauces 07 

Antrum  of  Highmore 31 

diseases  of C58 

Aphthaj 674 

Appearance  of  dead  teeth 591 

Appliances  used  in  orthodontia.     480 

Aqueduct  of  Fallopius 62 

Arbuthnot,   on   mortality  from 

dentition HI 

Arrangement  of  gold  in  filling 

teeth 322 

Arsenical  paste  as  acauseof  ulitis    541 

Arterial  tumors 938 

(1077) 


1078 


INDEX. 


Arteries,  anastomosis  of. 62 

coronary 61 

facial  ..! GO 

lateralis  nasi 37 

lingual 71 

posterior  palatine 37 

ranine 71 

Arthritis 183 

Articulation,  of  a  denture 477 

teiujjoro-maxiliary 74 

Artificial  dentures 456 

muscles 9'Jl 

Ashhurst  on  structure  of  the  epi- 

theliomata 921 

Aspects  of  dental  caries 281 

Associative  lesions  of  first  denti- 
tion   Ill 

Atheroma 815 

Atkinson's  phiggcrs 337 

Atlec's  suture 958 

Atomizers 429 

foot  instruments 430 

hand  instruments 429 

Atresia  oris 973 

Dietlen bach's  operation  for..  973 

Miitter's  operation  for 975 

Automatic  pluggers 348 

Autopsies  bv  Kokitansky  in  teta- 
nus ..". 189 

Baby's  sore-mouth 680 

Bad  ether 428 

Bamberger's  views  of  the  nature 

of  aphthie 679 

Barnum's  rubber  dam 312 

Bartholin's  duct 74 

Barton's  bandage 628 

operation  for  maxillary  tu- 
mor  '. 1067 

Batloy's  solution  in  cancer 930 

Bayberry  powder  in  hemorrhage  115 

Bean's  interdental  splint 632 

Beeswax  as  an  impression  mate- 
rial   469 

Belladonna,  in  tetanus 191 

in  tonsillitis 517 

Bichat's  tripod 127 

Bicuspid  teeth 96 

])roximal  cavities  in 345 

Bilateral  luxation  of  jaw 637 

Billroth  on  caries  of  bone 554 

on  classification  of  tumors...  875 

on  necrosis 580 

on  the  cystomata 898 

on  tumors 805 

Black's  engine 290 

Blisters  in  periodontitis 153 

Blood  eflusions 811 

Blue  line  in  saturnine  affections  550 

Bone,  ethmoid 46 


Bone,  hyoid 55 

inferior  maxillary 33 

inferior  turbinated 45 

lachrymal 54 

malar 53 

nasal 52 

palate 41 

sphenoid 48 

superior  maxillary 33 

Bon  wille's  electro-magnetic  mal- 
let   348 

engine 290 

Breaks  in  the  hard  palate 577 

Bridgman's  electro-chemical  ex- 
periments    261 

Broach,  use  of. 384 

Bromide  of  potash  in  ulitis 114 

Buckingham's  obturators 1040 

BuUffi 137 

Bur  files 352 

Burnishers 339,  352 

Burns,  ])]astic  operations  for  re- 
lief of. 992 

Butler's  pluggers 339 

Calcification  of  dental  jjulp....  366 

Calculi  in  salivary  ducts 497 

Camper  on  mortality  of  infants..  -  111 

Canal,  Failojiian 88 

infraorbital 81 

1  nterpalati  ne 43 

lachrymal 31,  35 

plerygo-palatine 42 

vidian 52 

Canal  pluggers 387 

Canals,  Haversian 99 

Cancer  of  gums 919 

of  Stenonian  duct 920 

of  tongue 769 

Cancrum  oris 677 

Canine  teetii 95 

Caps  for  exposed  dental  pulj)s...  153 

in  dental  inflammation 153 

Capsular  ligament  of  lower  jaw  75 

Capsule  of  encejihaloid  cancer...  915 
Carbonate  of  magnesia  in  phos- 

plior-poisoning 586 

Carcinoma  of  jaw 914 

of  lingual  fossa 708 

of  submaxillary  region 708 

Caries  as  cause  of  death  of  teeth  571 

Caries  of  maxillie 552 

affinity  with  cellular  -struc- 
ture   556 

illustrative  cases  of 563 

scrofulous  associatii)ns 552 

treatment  of. 563 

by  acids 561 

Caries  of  the  teeth 214 

cachexia  in 215 


INDEX. 


1079 


Caries  of  the  teeth,  causes  of. 214 

constitutional  relations 25o 

diifers  from  caries  in  bone..  274 

inflammatory  process  of. 274 

principles  of  treatment 27(5 

Carious  denture 297 

Carotid  arterj^ (jG 

Catalan's  inclined  jilaiie 48'J 

Catarrh    of  Schneiderian   mem- 
brane   G70 

Cathartics  in  neuralgia 783 

Causes  of  dental  abscess 175 

of  gum  diseases 532 

of  odontalgia 361 

of  sensitive  dentine  304 

Caustic  potash   in  treatment  of 

caries  of  bone 6fi2 

Cauterizing  sensitive  dentine 303 

Cavities   in    teeth,  rules  in   ex- 

ca  vati  ng 305 

Cementum 98 

Chali^y  teeth 279 

Changes  in  rami  of  lower  jaw...  489 

Character  of  epithelioma 926 

Cheeks,  composition  of 58 

Cheever,    osteoplastic    resection 

of  jaw 1065 

Cheilopla'sty 980 

operation  by  M.  Blasius 984 

bv  Chopart 982 

by  Dieffenbach 984 

bv  Dupuvtren 983 

by  Horn.^ 982 

by  Liston  985 

by  Mr.  Morgan 984 

by  Mutter. .7 985 

bv  Ivoonhuj'sen 982 

by  P.  Koux 984 

by  T.  M.  Roux 984 

by  M.Serres 983 

Chimney-sweep's  cancer 919 

Chisels  used  in  dentistry 291 

Chloride  of  zinc  in  sensitive  den- 
tine   363 

Chloroform 441 

action  of 442 

at  ditferent  temperatures  443 

in  association  with  age 448 

with  hysteria 449 

with   strength   and   de- 
bility ....': 449 

in  cerebral  disease 452 

in  disease  of  the  heart 450 

in  diseases  of  the  lungs 450 

in  insanity 453 

in  pregnancy ' 450 

Chloroma 814 

Chromic    acid    in   treatment  of 

warts  of  the  face 949 

Chronic  periodontitis 149 


Cicatrix  in  hare-lip 061 

Ciliary  ganglion 87 

Clasp  teeth 4(57 

Cleft  lip 0(57 

palate Kuii) 

operation  by  Fergusson  1021 

by  Garretson I(i21 

by  Roux 1020 

by  Warren 1020 

Clinical  distinction  of  tumors...  806 

histories  of  ntcvi 945 

peculiarities  of  carious  bone  557 

Cloquet's  ganglion 87,  89 

Cobweb  in  hemorrhage 115 

Cold  in  anaesthesia 429 

Color  in  calculi 502 

Columnar  epithelium 72 

Comminuted  fractures 633 

Complete  luxation  of  jaw 637 

Complexion  in  necrosis 588 

Complicated  dental  cavities. ..298,  308 

fractures 633 

hare-lip 9G4 

wounds 609 

Compression  in  hemorrha<i:e 599 

Condensation  of  fillings 354 

Condyloid  processes 40 

condition    of,    in    luxa- 
tion   638 

Congenital  luxation  of  jaw 640 

tongue-tie 802 

union  of  gums 547 

Conjoined  loss  of  nose  and  lip...  989 
Constitutional  diseases  associated 

with  antral  disease G64 

Contour  lillings 304,  347,  355 

Contracted  dental  arch 142 

Contracted  oral  orifice  973 

treatment    of,    bv    Dietren- 

bach : 973 

ti-eatnient  of,  by  Miitter 975 

modification  of,  by  Gar- 

retson 976 

Convulsion    from    irritation    of 

teething 92 

Corks,  use  of,  in  jaw  luxation...  641 

Coronary  arteries 61 

Corpuscles,  Purkinjean 99 

salivary 276 

Cow-horn  forceps 406 

Crapulous  diarrhrea 1-7 

Croasote  as  a  cause  of  ulitis 540 

in  dental  caries 280 

in  treatment  of  caries 565 

Cribriform     plate    of    etiunoid 

bone -iG 

Crista  gain  of  ethmoid  bone 46 

Crusta  petrosa ^8 

Cuspidati  teeth •••} 

Cutting  forceps ■*!•> 


1080 


INDEX. 


Cutting  teeth,  irritation  from...  112 

Cy.stic  tumor  of  cheek 933 

Cystoma  of  parotid  region 931 

Cysts,  general  diagnosis  of 816 

of  antrum 870 

from  dental  ab.scess 817 

of  salivary  ducts  and  glands  696 

of  tongue 77G 

of  tonsil  glands t)'l(i 

Cytoblasts 105 

Data   for   diagnosis   of  dental 

tumors 867 

Dead  teeth,  how  exfoliated 571 

Death  of  teeth   from   structural 

consolidation 571 

Deciduous  teeth 93 

tooth  -pu  1  |i 143 

Deep-seated  ranula 7<*') 

Dental  abscess 170 

anomalies 141 

caries 214 

from  accidental  causes.  269 

from  acid  secretions 257 

from    agents   in  contact 

with  the  teeth 254 

from   constitutional  re- 
lations    253 

from  dyspepsia 254 

from     electro-chemical 

relations 261 

from     mechanical     de- 
structives   209 

from  medicines  and  ar- 
ticles of  food 267 

from  mucous  deposits...  255 

from  parasites 259 

from  rickets 215 

from  scrofulosis 215 

from  shape  of  teeth 251 

from  syphilis 215 

chairs 325 

fever 124 

fistula 170 

irritation,  epileji.-y  from  ....  133 
influence  of,  im  skin  dis- 
eases   136 

necrosis 568,  669 

neuralgia 736 

periostitis 149 

pulp 102 

svringe ; 305 

Dentifrices.... 270 

Dentisrerous  tumors 846 

Dentine 97,  103,  105 

consolidation  of 275 

Dentinoma 815 

Dentition  as  a  cause  of  ostitis....  568 

first,  associative  lesions  of...  Ill 

di-arrhcea  from 126 


Denudation  of  enamel 505 

cause  of 605 

Dermatitis 135 

Desirabode's  obturators 1047 

Destroying  dental  jjuIj) 371 

results  of 570 

Devitalized  dentine 390 

Dewar's  dressing 959 

Dewees's  views  on  the  aphtluw...  680 

views  on  tongue-tie 801 

Diagnosis  of  carious  dentures 297 

of  epithelioma 922 

of  luxations 638 

of  maxillary  caries 554 

of  maxillary  tumors 808 

of  ranula 696 

Diarrluoa  from  milk  of  nurse 127 

of  dentition 126 

Diel!enbacir.s  button  obturator..  1031 

Digitalis  in  tetanus 191 

Diminution  of  pulp  chamber 377 

Diseased  teeth  as  cause  of  antral 

trouble 659 

Dislocation  of  inferior  maxilla..  426 

Dissection  of  soft  palate 1016 

Domestic   treatment  of  holes  in 

the  j.alate 1032 

Drilling  engines 290 

Drills..': 288 

Dropsy  of  the  antrum 663 

Dryness  in  filling  teeth 308 

Dubs's  screw-force])s 417 

Duct  of  Bartholin 74 

Kivinian 74 

of  Steno 73 

of  Wharton 74 

Ductus  ad  nasum 31,  35,  54 

Duplay's  nasal  spi-culum 657 

Duration  of  shock 603 

Ebcrnification  of  dentine 280 

Precentric  fibromata 877 

Ecthyma 139 

Eczema 139 

Efl'ects  of  tartar 495 

Efl^usions  in  synovitis 183 

Electro-chemical  cause  of  dental 

caries 261 

experiments  with  amalgam.  286 
explanation  of  dental  denu- 
dation   505 

Electro-galvanism  in   tooth  ex- 
traction   428 

Electro-magnetic  mallet 348 

Elephantiasis 139 

Ellipse  in  hare-lip 957 

Elsberg's  mouth-gag 1028 

Enamel 97,  105 

calcification  of 103,  106 

formation  of. 102,  105 


INDEX. 


1081 


Enamel  nodules 835 

pulp 102,  105 

Encephaloma 815,  915 

Enchondroma 815 

Enlarg-ement  of  tonsil  glands 519 

Ententis 128 

Epidemics,  furuncular 671 

Epiglottis 71 

Epilepsy  from  irritation  of  teeth- 
ing        92 

Epithelioma 918 

forms  of. 918 

from    irritation    of  jagged 

teeth 919 

llustrations  of. 918 

of  eyebrow 992 

treatment  of,  by  plastic 

operation 992 

of  tongue 773 

pearl  formations 926 

treatment  of,  by  caustics 927 

by  excision 927 

by  injection 927 

Epulides 819 

erectile 822 

fungoid  growths 819 

illustrative  cases 827 

non-explaining 825 

Erectile  tumors 937 

Erigeron  Canadensis 115,  425 

Eruption   of  teeth,  convulsions 

in 133 

Eruptions  on  skin  from  dental 

irritation 135 

erythema 135,  138 

exanthemata 138 

Erysipelas 133,  138 

as  a  complication  in  epithe- 
lioma  , 930 

Esmarch's  operation  in  jaw  an- 
chylosis      209 

Ethmoid  bone 46 

Example  in  tumor  diagnosis  ....     809 
of  anomalies  in  dental  evolu- 
tion  159-169 

Exanthemata 138 

in  antral  diseases 672 

Exanthematous  necrosis 508 

Excavators 287,  301 

Excising  forceps 189 

Excision  of  tonsil  glands 523 

Exfoliation  of  dead  teeth 571 

Exostosis 833 

Experiments  of  French  Academy 

with  ether 437 

Exposure  of  dental  cavities 294 

of  dental  pulp 365 

in  milk  teeth 143 

of  nares 1009 

Expressions  of  encephaloma. .915,  916 


Extension  fingers 311 

Extirpation  of  superior  maxilla.  1061 

of  tonsil  glands 525 

Extraction  of  teeth 39.5 

indications  for 395 

instruments  used  for  397,  413 

of  deformed  teeth 417 

Exuberant  granulations  in  caries    552 
Eye  teeth 95 

Face,  anatomy  of. 29 

Facial  arteries CO 

branches  of 61 

nerves 62 

neuralgia 737 

paralysis 739 

veins  63 

Fallopian  aqueduct 62,  88 

Fang  of  tooth 91,  103 

Fatty  tumors  of  cheek 934 

Fauces,  inflammation  of. 119 

isthmus  of 67 

pillars  of 67 

Fergusson  on  exposure  of  max- 
illa   1063 

Fever,  irritative 113,  124 

Fibrinous  blood 985 

Fibroma 815 

Fibrous  tumors 877 

Fifth  pair  of  nerves 77 

excitor  to  portio  dura 92 

to  respiratory  nerves  ...       92 

functions  of 90 

irritation  of,  in  teething 92 

File,  the,  as  a  prophylactic  agent     356 

Files 85,  118,  293,  352,  459 

Filling  teeth 281,  346,  382 

over  exposed  pulps 389 

pulp  chambers  and  canals...     384 

Finishing  fillings 351 

First  dentition,  associate  lesions 

of. Ill 

Fissure  of  hard  palate 1009 

congenital 101 1 

pressurein  treatment  of  1013 

uranoplasty  in 1028 

of  soft  palate 1014 

of  Sylvius 51 

of  tongue 761 

Fistula?,  of  tongue "67 

salivary '"'07 

Fixed  alkalies  in  tetanus 191 

Flagg's  tongue-holder 309 

Floor  of  mouth 40 

Fluids  of  oral  cavity 275 

Fly-blisters  in  jicriostitis 153 

Follicular  inflammation 076 

Foramen,  anterior  palatine 89 

inferior  dental 40 

infraorbital 32 


1082 


INDEX. 


Foramen  laccrum 50,  51  i 

liicerum  basis  cranii 88  i 

mental 31,  91 

ovale 50,  88 

rotundum 50,  81 

spheno-palatino i'l,  89  i 

spinosuin 50  I 

stylo-mastoiJ 63  I 

vesalii 50 

Forbes's  gouge  chisels 293  | 

rubber-dam  appliance 320  i 

Forceps  for  extracliiig  teetb 399 

cow-horn 407 

Dubs's 417 

HuUihen's 417 

Hutchinson's 409 

Jones's  fulcrum 412 

Perrine's  fulcrum  413 

Phvsiclc's 410 

Stellwagen's 415,  410 

Stromever's 012 

Foreign  bodies  in  nares 055 

particles  in  wounds 598 

Forget  on  dental  anomalies 155 

Forms  of  gold    used   in   lilling 

teeth. 322 

of  iiaro-lip 900 

of  maxillary  displacements..  637 

Formula  for  chloroform 441 

for  sulphuric  ether 422 

Fossa,  canine 31 

incisor 32 

lingual  is 71 

myrtifoi-m 30 

spheno- maxillary 81 

Fractured  tooth  root's 414 

Fractures  of  maxill'je 023 

Frsenuin  linguic 28 

Frail  anterior  teeth 283 

Freckles 139 

Frontal  nerve  80 

Full  dentures 475 

Functional  tumors 814 

Fungi 259 

in  dental  caries 280 

in  salivary  calculi 502 

Furuncular  epidemics 671 

Gags  for  holding  the  mouth  open  1029 

Elsl.erg's 1028 

Good  Willie's 1029 

Kolbe's 207 

Whitehead's 1029 

Wood's 1029 

Ganglion,  ciliary 86 

Cloquet's 89 

Gasser ian 79,  83-86 

intumescentiagangliformis62,  08 

lenticular 87 

Meckel's 52,  86,  87 


Ganglion,  ophthalmic 80 

otic 89 

semilunar 79 

spheno-jialatine 86 

submaxillary 89 

Gangrenaj  oris 078 

Garangeot's  obturator 1055 

Geist,  on  local  origin  of  phos- 

phor-neci'osis 585 

Genial  tubercles 40 

Genioplasty 980 

Gibbs,   Sir  Duncan,  on   uses  of 

uvula 592 

Glacial    acetic    acid    in   epithe- 
lioma    927 

Glands,  salivary 72 

parotid 72 

sublingual  40,  74 

submaxillarv 40,  73 

Glandular  tumors 930 

Glossitis 778 

Glosso-epiglottic  ligaments 71-72 

Glycerole  of  thymol 280 

Gold,  efl'ects  of,  on  the  teeth 275 

prei>ared  for  use  in  teeth....  322 

Good  on  the  aphth.'c 084 

Granulations  in  wounds 901 

Granules  in  dental  pul]) 374 

Green's  pneumatic  engim- 353 

Groove,  posterior  dental 36 

primitive- dental 101,  104 

Growth  of  maxillaj 142 

Guillois'  cement 283 

Gum-boil 170 

Gummata  syphilitica  of  tongue.  761 

Gums,  congenital  union  of 547 

disea.ses  of 532 

how  to  lance 115 

Gunshot  injuries  of  jaws  and  face  634 

Gustatory  nerve 85 

Gutta-percha  as  a  material   for 

lilling  teeth 286 

as  a  material  for  taking  im- 
pressions    472 

H.EMATOMA 815 

Uainsby's  compressor 959 

use  of,  in  cleft  palate 1011 

in  hare-lip 900 

Half-arches  of  fauces 07,  09 

Hamamelis  Virs^inicus 153 

Hand-  and  foot-kthes 190,  191 

Ilandlesof  plugging  instruments  307 

Hare-lip,  and  operations  for 952 

viev/s  on,  of  Agnew,  Prof...  956 

Bransbv  Cooper 953 

Colle,  Prtf..    954 

Dupuytren 953 

Fergusson,  Sir  Wm 953 

Houston,  Dr 953 


INDEX. 


1083 


954 
9-33 
955 
288 
99 


Hare-lip, viewson,  of  Listen,  ]\Ir. 

Pancoast,  Pn-f 

Skev,  Mr 

Smi'th,  Prof.  H.  H 

Hatchet  excavators 

Haversian  canals 

Healing  wounds 607,  961 

Healthj'  bone  adjoining  caries...  561 

Hemorrhage,  after  lancing  gums  115 

after  tooth  extraction 42o 

alum-water  in 115 

bayberry  powder  in 115 

Erigeron  Canadense  in.  115 

'  Monsel's  solution  in 116 

nitrate  of  silver  in 116 

opium  and  lead  in 115 

in  operating  ft)r  caries 561 

in  operating  for  tongue-tie...  803 
Guersent's    recommen- 
dation    803 

Petit's     instrument    to 

control 803 

in  operating  for  wounds  of 

face V 599 

Hereditary  dental  caries 214 

Herpes 139 

Heterogeneous  dental  evolution  155 

Heterologous  tumors 807 

Hill's  stopping,  for  carious  teeth 

as  a  pulp  cap 

Histoid  mixed  tumors 

Histology  of  epithelial  cancer... 

of  tumors 815 

Hodson  on  uses  of  rubber-dam...  313 

Hoe  excavators 287 

Holes  in  the  palate 1026 

hard  palate 1027 

soft  palate 1026 

Homologous  tumors 812 

Horn  and  Thornwaite's  means  of 

local  anaisthesia 427 

Horner's  operation  for  salivary 

fistula 509 

Horn-like  tumors 951 

Hot-air  sj-ringe 321 

Hot  and    moist  applications  in 

neuralgia 

HuUihen,    case   of    plastic    sur- 

g«T 

Hullihen's  screw  forceps 417 

Hulme  on  pulp  calcification 376 

Hydatid  cysts 817 

Hydrastis  Canadensis  in  epithe- 
lial cancer 928 

Hvdrops  antri 871 

Hygroma 700,  815 

Hj'oid  bone 54 

Hyperemia 136 

Hyperostosis 833,  839 

Hypertrophic  tumors 814 


952    Hypertrophy  of  gums ,543 

of  tonsil  glands 519 

Hysteria  and  anesthesia 448 


286 
393 
904 
920 


733 
994 


Ichthyosis 1 38 

Idiopathic  tetanus 187 

Idiosyncrasies,  use  of  ether  in...  439 
Illustrations   of    dental   anoma- 
lies   157-169 

of  epulides 827 

of  exostoses 842 

of  irregular  dentures 480 

of  obturators 1037 

of  the  odontomata 854-859 

of  ranulte 699 

of  staphyloraphy 1014 

uf  trismus ." 198 

of  wounds  of  the  face 609 

Imperfect  dentures 251 

Impetigo 139 

Impressions  for  dentures 467 

gutta-percha  for 472 

plaster  for 471 

trays  for 468 

wax  for 469 

for  obturators 1033 

Incisor  teeth ; 93 

India-rubber  as  a  .substitute  for 

muscle 971 

Indications     in     treatment     of 

W(junds  of  mouth 598 

of  dental  caries 274 

of  jaw  fractures 627 

Infantile  trismus 193 

Inferior  dental  arterv 37,  40 

dental  nerve .'..39,  40,  79,  1070 

maxilla,  changes  of 489 

fractures  of 623 

maxillary    bone,     anatomv 

of '.  38 

turbinated  bone 45 

Inflammation  of  dental  pul)) 365 

of  fauces 119 

of  jaw 567 

of  periodonteuin 149 

of  the  skin 136 

of  tonsil  glands 516 

Inflammatory  tuiiiurs 812 

Infraorbital  canal 81 

foramen 31,  36 


61 

2S0 
450 
182 
629 


Ingrassias,  processes  ot 

Injury  to  teeth  from  zinc 

Insanity  and  chloroform 

Interarticular  anchylosis  of  jaw 

Inderdental  splints 

Bean's <.i32 

Gunning's  031 

Interglobular  spaces  in  teeth.....       99 

Intermaxillary     jjrojeclions     in 

hare-lip 905 


1084 


INDEX. 


Introducing  fillings  into  teeth...  307 

Inversion  of  lip 1074 

Iodide  of  potassium  in  sj^philis.  766 

Iodine  in  treatment  of  caries....  564 

Iron  in  epithelioma 928 

and  quinine  in  erysipelas  ...  930 

Irregularities  of  the  teeth 272,  478 

of  system  at  large 570 

Irritation  of  dental  pulp 365 

Irritative  fever 124 

Isthmus  of  fauces 67 

Jack's  chisels 292 

matrices 327 

porte  polishers 353 

Jagged  teeth  in  tongue  diseases.  759 

Jaw,  anchylosis  of. 182 

fracture  of. 623 

Jenner  on  rickets 224 

Jourdain  on  aphtha? G84 

Kane,  E.  K.,  Dr.,  on  cold  as  a 

cause  of  tetanus 187 

Keloid  tumors 949 

Kennicutt  on  l)ulp  capping 392 

Kinds  of  tongue-tie 801 

Kingslev's  obturators 1056 

Kolbe'sgag 207,1029 

Lacerated  foramen 50,  51 

Lachrymal  bono 54 

canal 31,  35,  46,  54 

tubercle 35 

Lancing  the  gums 1 15 

hemorrhage  from 115 

treatment  of 115 

Langcnbeck,  osteoplastic  resec- 
tion   1065 

Larry,  Baron,  on  tetanus 187 

Leeches  in  periodontitis 154 

Lenticular  ganglion 87 

Lejiidoid  growths 948 

Lepra 138 

Lichen 137 

Lingual  nerve 85 

neuralgia 784 

Lipoma,  simuhiting  ranuia 698 

Lips 57,  58 

eversion  of 1075 

inversion  of 1074 

Lip-stretchor 1066 

Local    consideration   of    dental 

caries 250 

features  of  dental  abscess....     170 

Localized  stomatitis 113 

Lockjaw 182 

Loose  fragments  in  jaw  fractures     635 

Luj.us 139 

Luxation  of  inferior  jaw 637 


Mack's  retaining  screws 346 

in  contour  filling 346 

in  pivoting 464 

Macule 139 

Making  upper  lip 987 

Malar  bone 53 

Malformation  of  gums 547 

Malgaigne,  cheiloplasty 982 

Mallets'^in  filling  teeth 343 

Materials  used  in  capping  dental 

pulp 393 

in  filling  teeth 281 

in  taking  imj)rcssions 469 

Matrices,  in  filling  teeth 301 

Jack's  327 

Maxillary  bone,  inferior,  anat- 
omy of. 38 

condyloid  process 40 

inferior  dental  foramen  40 

mental  foramen 39 

mental  ))rocess 39 

mylo-hyoid  ridge 40 

ramus 39 

sigmoid  notch 39 

bone,  superior,  anatomy  of  33 

alveolar  processes 31,  34 

articulations 38 

malar  processes 35 

muscles  of 38 

nasal  processes 35 

palatine  process 37 

tuberosity 31,  34 

zygomatic  surface 36 

caries 552 

enlargement 142 

fractures 623 

necrosis 566 

Mayo,  experiments  of,  on  func- 
tions of  fifth  nerve 90 

McQuillen      on      interglobular 

spaces  in  dentine 99 

on    microscopy   of    morbid 

growths 836 

on  orthodontia 484 

McQuilleu's  extension  finger 311 

metal  cap  in  jieriodontitis...  154 
3Ieans  of  dryness  in  dental  opera- 
tions   308 

Barnum's  rubber  dam 313 

Dibble's  saliva-pump 310 

Flagg's  tongue-holder 308 

Forbes's  fork 320 

Hawes's  compressor 309 

Hodson's  appliances 313 

hot-air  syringe 321 

^[cQuillen's  extension  finger  311 

Morrison's  compressor 309 

napkin 308 

porcelain  tongue-thimble...  310 

Kich's  duct  compressor 311 


INDEX. 


1085 


Means  of  dryness  in  dental  opera- 
tions : 

Smith's  compressor 310 

Taft's  extension  finger 311 

Means  used  in  finishing  fillings..  355 

Meatus,  inferior 49 

middle 45,  48 

superior 49 

Mechanical  pressure  in  treatment 

of  anchylosis 200 

in  treatment  of  ranula 707 

Mechanism  of  asphyxia 436 

Meckel's  ganglion. 52,  82 

Medullary  carcinoma 914 

Melanoid  nsevi 954 

Melanoma 815 

Meliceroma 815 

Menstrual  period  and  anassthe- 

sia 450 

Mental  foramen 31,  39 

Mercurial  enlargement  of  tongue  7G7 

exostosis 836 

impressions 534 

necrosis 568 

ulceration 767 

Mercury  in  tetanus 191 

Merry's  drill 290 

Metal  pivots 462 

Metallic  ligatures 608 

Metals  as  a  cause  of  dental  ca- 
ries   269 

Metz's  nasal  speculum 657 

Microscopical   analysis   of   oral 

debris 261 

anatomy  of  teeth 99 

view  of  encephaloid  section  916 

of  epithelial  section 920 

Miliaria 139 

Milk  teeth 93 

Model  of  jaws,  making 473 

Modified  hare-lip  operation 964 

Moist  and   hot   applications   in 

neuralgia 733 

Molar  teeth 96 

Moles 946 

Molluscum 139,  948 

Monsel's  solutions  of  iron  in  epi- 
thelioma   927 

in  hemorrhage 116 

in  odontalgia 143 

Morphia  in  cancer 928 

in  neuralgia 733 

Morrison's  engine 290 

tongue-holder 309 

Mortality  of  infants Ill 

Morton,  Dr.  T.  G., operation  for 

anchylosis  of  jaw 210 

Mother-marks 139 

Mott's  operation  for  jaw  anchy- 
losis   981 


Mouth,  features  of 57,  58 

floor  of 40 

mirrors 305 

mucous  membrane  of 72 

offices  of 57 

roof  of. 58,  65 

sectional  expression  of 65 

washes  for 257 

wounds  of 598 

Mouth-stretcher  used  in  atresia 

oris 978 

Mucoid  sarcoma 879 

Mucous  cysts 72 

engorgement  of  antrum 667 

follicles 72 

membrane  of  mouth 60 

Multiple  cysts  of  antrum 872 

Muscles,  artificial 991 

of  expression 59 

Myeloid  tumors 879 

Myeloma 815 

Mylo-hyoid    ridge    of    inferior 

maxilla 40 

Myxoma 815 

N^vi 139,937 

treatment  of 937 

by  caustics 941 

by  compression 941 

by  electrolysis 942 

by  excision 939 

by  injection 941 

by  piecemeal  removal..  944 

by  strangulation 940 

Napkins,  dental 308 

Narcotics  in  tetanus 191 

Nasal  bone 32,  52 

cavity 44 

groove 43 

nerve 37,  43 

process 43,  113 

speculum 657 

Naso-palatine  ganglion 87,  89 

Neck  of  tooth 27 

Necrosis,  alveolar 568 

definition  of 566 

dental 568 

exanthematous 565 

mercurial 568 

phosphoric ^ 568 

syphilitic 568 

traumatic 565 

Nelaton's  method  in  reduction  of 

jaw  luxations 642 

Nerve,  anterior  dental 83 

auriculo-tenijidral 85 

buccal 85 

ciliary 81 

deep  temporal 85 

facial 62 


1086 


INDEX. 


Nerve,  fiftli 77 

excitor  to  portio  dura..       92 
excitor    to   respiratory 

nerves 92 

functions  of 90 

frontal 80 

ganglionic 81,  82 

inferior  dental,  section  of....       152 

inferior  niaxiilar}' 79,  83,  90 

infratrochlear 81 

labial 83 

lachrymal 80 

lingual  or  gustatory 8o 

masseteric So 

nasal 80,83 

naso-palatiiie 37,  43,  89 

of  the  face 62 

tonijue 71 

ophthalmic 79,  90 

orbital 82 

palpebral 83 

portio  dura 02 

posterior  dental 82 

pterygoid 8o 

superior  maxillary 79,  81,  90 

supraorbital 80 

supratrochlear 80 

trifacial 77 

trigeminus 77 

Nerve,  sections  of. lOC.o 

Carnochaii's  operation.   1072 
Pancoast's  operation....   1072 
sections   of  inferior  maxil- 
lary   1009 

of  superior  maxillary...   1071 

Neuralgia 709 

causes  of. 711 

from  depression 714 

from  derangements  in   res- 
piration      713 

from  gout 710 

from  granules  in  dental  pulp     375 

from  miasma 710 

from  rheumatism 710 

from  sy]ihilis 710 

illustrative  cases 717 

nature  of. 710 

not  a  disease 710 

pain  of 709 

relations  of  tobacco  with....     717 

Neuroma 815 

Nitrous  oxide  gas 454 

liquid 454 

surgeon's  case 454 

Nodular  dentine 379 

Nodules  of  enamel 353 

Non-explainable  tumors 874 

Non-specific  exostosis 834 

Notch,  in  hare-lip 962 

sigmoid 962 


Obstruction    of    submaxillary 

duct 705 

Obturators 1030 

dies  for  making 1034 

fixing  in  the  mouth 1036 

impressions  for 1038 

models  for 1033 

by  Buckingham 1040 

b}'  Garangeot 1055 

by  Kingsh'v 1057 

by  McGrath 1038 

by  Pare 1054 

by  Snell 1055 

by  Stf'arn 1056 

by  Wildmnn 1048 

Occi|)ito-froiital  tjanJage 633 

Odontalgia  from  c(uitinement  of 
pus  and  gas  in  pulp  cham- 
ber      372 

from   disease   of   periodon- 

teum 149 

from  exposure  of  dental  i)ulp 

to  sources  of  irritation 365 

from  granules  in  pulp 374 

from  recession  and  absorp- 
tion of  gum  and  alveolus.     380 

from  sensitive  dentine 361 

from  sympathv 380 

Odontocele '. 31,  850 

Odonto-cephalalgia 380 

Odonto-gastralgia 380 

Odonto-otalgia 361 

Odontoma 853 

(Edema  of  glottis 528 

Offensive  odor  of  saliva 257 

Offices  of  uvula 529 

Oidium  albicans 675 

Oilier,    exposure    of    niaxillary 

tumors 1065 

Opacity  of  the  teeth 373 

Operations  about  the  cheeks  and 

lips 952 

for  treatment  of  neuralgia...     737 
for     treatment   of    tongue- 
tie 801 

on  oral  commissure 987 

Opercula 101,  105 

Ophthalmic  nerve 79 

Opisthotonos 187 

Opium  and  lead  in  hemorrhage.     115 

Oral  fungi 259 

Orbit 31 

\  Orthodontia 478 

Osseous  tumor „ 840 

Ossific  diathesis 833 

Osteoma 815 

Osteoplasty 283 

Ostitis  during  dentition 568 

preceding  necrosis 566 

Otic  jranglion 841 


INDEX. 


1087 


Oxychloride  of  zinc 283 

as   a   capping    for    exposed 

palps 391 

as  a  filling  for  carious  teeth  283 

Ozffina,  causes  of. 644 

from  accumulation  and  de- 
generation of   antral 

secretions G44 

caries  and  necrosis 655 

caries  of  osseous  walls  of 

antrum 654 

degenerated    pus   from 

tooth  abscess 645 

deteriorated    secretions 

from  systemic  causes.  652 
lodgment  and  retention 

of  foreign  bodies 655 

ulceration  of  antral  lin- 
ing   646 

Paget  on  healing  wounds 961 

Palate  bones 41 

Pahitine  defects   and  treatment 

of 1009 

proce.*.s 37 

Pancoast,    opei-ation    in    cheilo- 

plasty 981 

Papilla3  of  tongue 70 

circum  vallate 70 

filiform 71 

fungiform 70 

of  teeth 101,  104 

Papulre 187 

lichen 137 

prurigo 137 

stropliulus  137 

Paralysis,  facial 739 

of  cheek 989 

artificial  muscleused  for  991 
treatment  of,  by  opera- 
tion  '. 990 

Parasites,  oral 259 

Parasitic  cysts 817 

Parotid  gland  72 

Pai  tial  dentures 474 

Parulis 170 

Paste  fillings  for  carious  teeth...  284 

.Patliologv  of  tetanus 187 

Paul,  Dv.  J.,  on  food 239 

Pearly  teeth 279 

Peculiar  articulation 476 

calculi 497 

Pempliigiis 138 

Period  for  hare-lip  (peration  ....  952 

Periodonteum 99 

abscess  of 170 

afteeting  antrum 661 

inflammatitm  of 149,  372 

Permanent  ranulse 699 

Permanent  teeth 93 


Petronius's  obturator IO.54 

Pharyngitis  leuciemia 549 

Phosphor-necrosis 584 

complexion  in 588 

of  upper  jaw 592 

salivation  in 588 

sequestra  of 588 

theory  of  Dr.  Letbeby .585 

of  Lorinser , 585 

of  Von  Bibra  and  Geist  585 

Pigment 945 

Pimples 1,37 

Pins  in  hare-lip  operation 972 

arranging  ligatures  about...  972 

manner  of  itsing 972 

Pityriasis '^ 138 

Pivot  teeth 456 

Plaster  of  Paris  as  an  impression- 
material  471 

Plasters,    use    of,   in    dressing 

wounds 608 

Plastic  operations  in  treatment 

of  iaw  anchylosis 211 

Plate  teeth 467 

Pleurosthotonos 187 

Plugging  teeth 280 

instruments  used  for 341 

Abbott's  pluggers 341 

Atkinson's  pluggers 338 

Butler's  pluggers 339 

Redman's  pluggers 324 

Varney's  pluggers 340 

Poison,  typh 255 

Pompholyx 138 

Por  rigo 139 

Porte  polishers 353 

Posterior  dental  canal 36 

dental  groove 36 

dental  nerve 36 

palatine  artery 37 

pillars  of  fauces 67 

Predisposing  causes  of  tetanus..  187 

Pregnancy  and  anesthesia 450 

Premature  dentition 112 

Premolar  teeth  96 

Preparation  of  mouth  for  arti- 
ficial teeth 467 

Prescriptions  for  toothaciie 366 

Pressure   in   cleft  of  hard   pal- 
ate   1011 

in  epithelioma 925 

in  hemorrhage 599 

in  ranula "07 

in  separating  teeth 299 

Primary  sac  of  tooth 106 

Primitive  dental  groove 101,  104 

Processes  of  condyloid 40 

of  Ingrassias 51 

of  keloid  growths 950 

Prodroma  of  tetanus 187 


1088 


INDEX. 


Prognosis  in  synovitis 183 

Progressiveness  of  caries 556 

Prophylaxis    for    phosphor-poi- 

eoning 685 

Proposition  in  etiology  by  Bill- 
roth   913 

Protoxide  of  nitrogen 454 

Protrusion  of  lower  jaw 489 

use  of  occipito-mental  sling 

in 490 

Proximal  cavities 344 

fillings,  tinisiiiiig 354 

Psoriasis  of  tongue 762 

Pulp  of  tooth 97,  102 

exposure  of 365 

fungoid  tumors  of 820 

Purkinjean  corpuscles  in  cemen- 

tum : 99 

Purpura 138 

Purulent  discharge  from  antrum  664 
Pus    and     gas    in    dental    pulp 

chamber 372 

Pustulaj 139 

ecthyma 139 

impetigo 139 

porrigo 139 

scabies 139 

variola 139 

Pyogenic  membrane 170 

Rakula 695 

diagnosis  of 697 

distinguished    from     carci- 
noma    708 

hygrometric    tumors    simu- 

'iatiiig 700 

lij)oma  simulating 698 

nature  of 695 

salivary  and  lympliatic  ade- 
nitis simulating 701 

salivary  calculi,  causes  of....  706 

treatment  of 696 

by  mechanical  pressure  707 

by  operation 703 

Rashes 136 

Recession  of  the  gums  382,  545 

Recipes  employed  in  neuralgia..  753 

for  tt)oth  powders 258 

Redman's  pluggers 324 

Reduction    of   maxillary    luxa- 
tions    639 

Reflex  pain  from  dental  pul^....  373 
Reina's  operation  for  jaw  anchy- 
losis   218 

Relation  of  first  to  second  den- 
tures   142 

of  medicines  with  dental  ca- 
ries   267 

of  phosphorus  to  jaw-bones.  584 

of  tumors 812 


Remarks  on  extraction  of  teeth.  422 
Requirements  in  metals  for  fill- 
ing teeth 281 

Resection  of  fractured  bones 633 

of  inferior  maxilla 1014 

of  superior  maxilla 1064 

Retention  of  antral  secretions...  065 

Rheumatism,  combination  for...  369 

Rheumatoid  arthritis 186 

Rhinoscope,  uses  of,  in  ozjena  ...  657 

Rich's  duct  compressor 311 

Richardson's  atomizer 429 

Rickets 220 

Ricord  on  syphilis 764 

Ridge,  mylo-hyoid 40 

Riggs's  operation  for  absorbing 

alveoli 382 

Rindfleisch  on  carcinoma 896 

on  caries  of  bone 552 

on  histoid  mixed  tumors....  904 

on  necrosis 568 

on  new  formations 807 

Rivinian  ducts 74 

Rizzoli's  operation  for  jaw  an- 
chylosis   209 

Root  filling 388 

Rose  drills 289 

Round-celled  sarcoma 878 

Rubber-dam 312 

Rubeola 138 

Rules  for  formation  of  cavities 

in  teeth 356 

for   treatment  of    gun-shot 

wounds 634 

Rumbold's  treatment  of  enlarged 

tonsils 522 

Rupin 139 

Ruppaner's  treatment  of  enhirged 

tonsils 521 

Saliva,  condition  of 276 

corpuscles  of 276 

microscopj-  of 276 

Salivarv  calculi  inducts 706 

fistlilie 507 

anatomy  of. 515 

anomalous  cases  of 507, 

511,  513 

causes  of 507,  560 

common      manner      of 

treating 508 

Garretson's     operation 

for 509 

Horner's  operation  for.  509 

glands 72 

Salivation  in  necrosis 579 

Salt  sheet  baths 118 

Salter  on  necrosis 574 

Sarcoma 815 

Sarcomatous  carcinoma 911 


INDEX. 


1089 


Scabies 139 

Scales 137 

Scarlatina 138 

Scars 607 

Schneiderian  menibrano 35 

Scirrhoma 815 

Scirrhus 905 

microscopy  of 910 

of  tongue 769 

Scorbutic  exostosis 836 

Scorbutus  and  antral  disease 672 

Screw  in  extracting  tooth-roots.  407 

in  jaw  anchylosis 209 

in  plugging  teeth 346 

Scrofulosis 217 

ulcers  of. 650 

Scrofulous  tumors 837 

Scurvy 536 

Sebaceous  tumors 932 

treatment  of 932 

Secondary  dentine 378 

Section  of  scirrhous  carcinoma..  770 

Sedatives  in  treatment  of  ostitis  568 

Self-explaining  cystic  tumors....  896 

Sella  turcica 49 

Semilunar  ganglion 79 

Sensibility  of  dentine 359,  361 

Separating  files 293 

Septum  nasi 43 

Sequestrum  of  necrosis 582 

Setting  pivot  teeth 456 

Sheet-lead  in  atresia  oris 979 

Shock 600 

Sigmoid  notch  of  inferior  max- 
illa  30,  41 

Sigmund,  Prof.,  on  syphilis 577 

Simple  cysts 846 

tumefaction  of  maxilla 837 

Sims,  Dr.   Marion,  on  cause  of 

infantile  trismus 194 

Skin-diseases 137 

Sloughing  of  nrevi 945 

Smith,  Prof.  H.  H.,on  epitheli- 
oma   923 

on  shock 601 

Smooth-faced  pluggers 337 

Sordes 277 

Sore  throat 120 

Source  of  vitality  of  tooth 570 

Spasm  from  dental  irritation 130 

treatment  of 134 

Spasmodic  trismus 205 

Spear  drills 289 

Speculum  of  Duplay 657 

of  Limrock 657 

of  Metz 657 

Spheno-maxillary  fissure 51,  81 

foramen 42 

fossa 81,  82 

Splieno-palatine  ganglion 


Sphenoid  bone 48 

Spiritus  nitri  dulcis 2C9 

Splints,  external,  for  jaw  frac- 
tures   628 

interdental 630 

Bean's 632 

Gunning's 630 

Sponge  gold 282 

Spots" 137 

Spurious  ranula 706 

Squamte 138 

ichthyosis 138 

lepra 1.38 

pityriasis 138 

psoriasis 138 

Stages  of  staphyloraphy 1018 

Steam's  obturator 1056 

Steatoma 815 

Stellwagen's  dental  case 341 

Stenonian  duct 73 

compressor 311 

Stomach  teeth 95 

Stomatitis 549 

Strophulus 137 

Structural  consolidation  of  den- 
tine   275 

resisting  caries 279 

Strumous  abscess  of  tonsil 524 

Studies  in  complicated  hare-lip..  967 

in  obturators 1037 

in  plastic  surgery 980 

Styles  of  excavators 287 

Stylo-mastoid  foramen 62 

Subcutaneous  epithelioma 925 

Sublingual  cysts 697 

gland 40 

ducts  of 74 

extirpation  of 74 

Submaxillary  fossa 40 

gland 40,  73 

triangle 40 

Sulphuric  acid  in  treatment  of 

osseous  caries 561 

Superficial  ranula 699 

Superior  dental  arch 25 

maxillary  bone 33 

fractures  of 624 

maxillary  nerve 79 

section  of. 1072 

Surgeon's  nitrous  oxide  case 455 

Surgical  relation  of  anomalies  in 

dentition 141 

Swallowing  the  tongue 803 

Sycosis J39 

Sympathetic  neuralgia 7  13 

odontalgia 380 

Symptoms  of  jaw  fracture 624 

of  tetanus 1^7 

Synonyms ^17 

Synovitis 1?'-^, 


68 


1090 


INDEX. 


Syphilis 225 

Syphilitic  adenitis 937 

aftections  of  tonsils 515 

cor3-za  in  infants 656 

disease  of  tonjjue 760 

epithelial  degeneration 922 

necrosis 568 

ozaena 652 

ulcers 577 

ulitis 568 

Taft  on  cause  of  dental  caries  ..     269 

Taft's  extensiun-tingor 311 

separating-lile 294 

Taking  impressions  467,  ltl33 

trays  required  for 468 

'Tartar 495 

treatment  of 503 

use  of  acids  for  removing...     504 
use  of  instruments   for   re- 
moving       504 

Teeth,  articulation  of 109 

bicuspidati 96 

canine 95 

ccraentum  of 97,  98 

crusta  petrosa  uf 96,  97 

cuspidati 95 

deciduous 93 

dentine  of 97,  103,  106 

development  of,  Garretson's 

views  on 104 

opinion  of  Beale,  Hux- 
ley, etc 104 

oj)inion  of  Goodsir 101 

opinion   of    Todd    and 

Bowman 101 

enamel  of 07,  1U5,  108 

eruption  of 104 

order  of 106,  112 

j)ermanent 108,  109 

temporary  sets 107 

eye 95 

fang  of 96,  103 

formation  of 101 

incisor 93,  94 

interglobular  sjiaces 99 

microscopical  anatomy  of...       99 

milk 93 

molar 96 

neck  of. 97 

ossitication  of 102,  105,  108 

papillio  of ...101,  104 

periodonteum  of 97,  99,  105 

j)ermanent 93 

premolar 96 

pulp  of 97,  105 

root  of .96,  106 

stomach 95 

temporary 93 

'  wisdom 96 


Temper    in     plugging     instru- 
ments   308 

of  drills 289 

Temperament  and  antral  disease  664 

Temperature  and  ether 439 

Temporary  ranulas 699 

Temporo-maxillary  articulation  74 

Test  for  purity  of  chloroform  ...  441 

Tetanus 387 

treatment  of 190 

Thimble,  porcelain 310 

Thrush 676 

Tic  douloureux 92 

Tin-foil 281 

Tincture  of  belladonna  in  con- 
gestion of  gums 114 

Tissu  inodulaire 961 

Tolerance  of  dead  teeth  by  jaws.  570 

Tongue  and  its  diseases 750 

abscess  of 783 

acute  inflanmiation  of 778 

carcinoma  of 769 

cystic  tumors  of 776 

ejiithelioma  of 771 

functional  expression 756 

holders 309 

Flagg's 309 

Morrison's 309 

Smith's 310 

neuralgia  of 784 

surgical  diseases  of. 758 

syphilitic  condition 761 

tubercle  of 775 

Tonsil  glands 516 

ablation  of 526 

acute  inflammation  of.. ...517,  526 

cysts  of 526 

hypertrophy  of. 521 

Tonsillolome 523 

Fahnestock's 523 

Kolbe's 523 

Physick's 523 

Torsion  in  hemorrhage 599 

Trachea,  anatomy  of 531 

Tracheotomj- 537 

Transjilantation  of  skin 986,  1007 

Traumatic  necrosis 568 

Treatment  of  alveolar  abscess  ...  176 

of  aphthic 690 

of  carious  bone 557 

of  carious  teeth 294 

of  epulo-fungoid  growths  ...  822 

of  erectile  growths 823 

of  irregular  dentures 479 

of  large  oral  cysts 868 

of  nievi.. 589 

of  non-explaining  epulides..  826 

of  periodontitis 153 

of  ranuhe 696 

of  shock 603 


INDEX. 


1091 


Treatment  of  synovitis 184 

of  ulitis 534 

of  umbilical  cord 195 

Trismus 182 

dentium 196 

from  filling  teeth 205 

nascentium 193 

tetanoid 207 

traumatic 206 

Tubercles 137 

genial 40 

of  the  tongue 775 

TuberculiB 139 

acne 139 

elephantiasis 139 

frambcesia 139 

moUuscum 139 

lupus 139 

phyma 139 

sycosis 139 

verruca 139 

vitiligo 139 

Tubular  consolidation  of  dentine  378 

Tumors 804 

Tunica  propria  of  tooth 106 

Typh  poison 255 

Typical  cancer-cell 811 

Ulcer,  aphthous 119 

of  dentition 114 

of  necrosis 576 

Ulcers 646 

Ulcus  rodens 923 

Ulitis 532 

Umbilical  cord  in  infantile  tris- 
mus   195 

Unadhesive  gold-foil 282 

Upperlip,  operation  for  restoring  987 

Uranoplasty 1028 

operation  of  Warren 1028 

Urticaria 136,  138 

Utilizing  parings  in  hare-lip....  963 

Uvula,  amputation  of. 530 

functions  of. 58,  528 

Vallet's  mass  in  epithelioma  ..  928 

Value  of  zinc  in  cancer 928 

Varicella 139 

Variola l^J^ 

Vascular  tumors 937 

Veins  of  face *33 

facial 65 

intermaxillary 65 

temporal 'j-j 

temporo-maxillary 65 

Velum  palati JjG 

Venereal  exostosis \ 836 


Venous  tumors 939 

Verruca 39 

Verrucous  growths 945 

Vesicles 137,  139 

Vesicuhe 139 

aphtha 139 

eczema 139 

herpes 139 

miliaria 139 

vaccinia 139 

varicella 139 

rupia 139 

Vicarious  menstruation 749 

Vidian  canal 52,  88 

nerve 52,  88 

Virchow  on  rickets 225 

on  tumors 807 

Virus  in  wounds 602 

Vitiligo 139 

Vomer,  anatomy  of 43 

Von  Bibra  on  phosphor-necrosis  565 

Warts  on  the  face 949 

Wartv  teeth 835 

Waxed  threads 359 

AVeber's  classification  of  tumors 

of  jaw 876 

Wedge  plugs 307 

in  filling  teeth 321 

in  orthodontia 491 

Wedl,  Prof.  Carl,  on  pulp  cavity  377 

Westcott's  correcting  appliance.  198 

Wharton's  duct 74 

White,  Dr.  J.  D.,  mode  of  cor- 
recting plate 483 

mode  of  pivoting 463 

Wildman,  nose  and  obturator....  1048 

Wire  sutures 633 

Wi.'^dom  teeth 96 

Wood  on  aphthaj 689 

on  functional  expressions  of 

tongue 7'56 

Wood  pivots 460 

Wood's  gag 1029 

Woodward,  Dr.  J.  J.,  papers  on 

histology 917 

on  woorara 191 

Woorara  in  tetanus 191 

AVounds  of  the  mouth 598 

Yellow  teeth 276 

Zinc,  action  of,  on  teeth 275 

in  treatment  of  cancer 927 

in  treatment  of  caries 364 

used  for  arrestof  hemorrhage    279 

used  for  purifying  amalgam  285 


i 


J.  B.  LIPPINCOTT  &  CO.'S 

CATALOGUE 


OF 


MEDICAL  AND  SURGICAL 

WORKS. 


AGNEW.— Hand-book  of  Practical  Anatomy.  By  D.  Hates  Agnew, 
M.D.  With  Illustrations.  Second  edition,  revised.  12mo.  Cloth. 
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The  Principles  and  Practice  of  Surgery.      Being  a  Treatise  on 

Suro-ical  Diseases  and  Injuries.  By  D.  Hayes  Agn'ew,  M.D.,  LL.D., 
Professor  of  Surgery  in  the  Medical  Department  of  the  University 
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AITKEN  —Outlines  of  the  Science  and  Practice  of  Medicine.     By 
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art  of  teaching." — British  Med.  Journal. 

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Studies  in  the  Facial  Region.  By  Harrison  Allen,  M.D.  Illus- 
trated.    8vo.     Cloth.     $2.00. 

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ASHHURST.— On  Injuries  of  the  Spine,  their  Pathology  and  Treat- 
ment.   By  Joux  AsuuuRST,  Jr.,  A.M.,  M.D.    12mo.    Cloth.    $1.50. 

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Al)dominal  and  Pelvic  Tumors  in  the  Female.     Their  Pathology, 

Treatment,  etc.     By  Washington  L.  Atlee,  M.D.,  and  Thomas  M. 
Drvsuai.e,  M.D.     With  Illustrations.     8vo. 

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BARTHOLOW. — A  Manual  of  Hypodermic  Medication.  By  Roberts 
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prudence. By  T.  R.  and  J.  B.  Beck,  M.D.  With  Notes  by  an  As- 
sociation of  the  Friends  of  the  Drs.  Beck.  New  and  thoroughly 
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OF  MEDICAL  AND  SURGICAL  WORKS. 


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of  Practice  of  Medicine  in  Jefferson  College.     12mo.     Extra  cloth. 
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4  J.  B.   LJPPIXCOTT  ^-    CO.'S   CATALOGUE 

DAMON. — Tho  Neuroses  of  the  Skin  :  tlieir  Patholosv  Jind  Treatment 
liy  Ilou-ARD  F.  Damon,  A.M.,  M.U.     8vo.     Cloth.' >2.U0. 

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Illustrated.     By  Howard  F.  Damo.v,  A.M.,  M.D.     Cloth.     §3.00. 

DRAKE. — A  Systematic  Treatise :  Historical,  Etiological,  and  Prac- 
tical, of  the  Priiici]ial  Diseases  of  the  Interior  Valley  of  North 
America,  as  they  a|i|)ear  in  the  Caucasian.  African,  Indian,  and 
Esquimaux  Varieties.  By  Daniel  Drake.  M.D.  Edited  by  S.  IIan- 
jtLRY  SiiiTU,  M.D.,  and  Francis  G.  Smith,  M.D.  ,8vo.  Sheep. 
?5.()0. 

DUHRING.— Atlas  of  Skin  Diseases.  By  Louis  A.  Duhring.  M.D. 
(Quarto.  To  he  puhlished  in  Ten  Parts,  each  containing  Four  Plates. 
With  Descriptive  Text.     Each  §2.o0. 

A  Practical  Treatise  on  Diseases  of  the  Skin.     By  L.  A.  Duiiring, 

M.D.     Illustrated.     8vo.     Cloth,  §6.00.     Sheep,  .S7.00. 
"  We  must  congratulate  Dr.  Duhring  on  having  ])roiluccd  a  thoroughly  work- 
manlike, practiciil,  and  coni])rchonsive  treatise  which  cannot  fail  to  increase  his 
reputation  as  a  derniatologit:t,  both  in  the  United  States  and  in  Great  Britain." — 
London  Medical  Timeg  and  Unzette. 

"  It  is  the  best  work  on  the  topic,  in  our  opinion,  in  the  language ;  and  to  the 
American  physician  deserves  to  supersede  all  others." — Philndetphia  Medical 
mid  S'lirificiil  lltporler. 

DUTCHER. — Pulmonary  Tuberculosis.  Its  Pathology,  Nature,  Symp- 
toms, Diagnosis,  Prognosis,  Causes.  Hygiene,  and  Medical  Treat- 
ment. By  Addison  P.  Dltcuer,  M.D.  Illustrated.  Crown  8yo. 
Extra  cloth.     §3.0(J. 

"  Few  men  in  our  country  have  given  the  subject  under  consideration  more 
thought  than  Dr.  l)utcher,  and  his  experience  has  been  ample.  While  wo  object 
to  portions  of  the  treatment  recommended  in  the  book,  we  are  bound  to  give  the 
author  credit  for  furnishing  the  profession  with  one  of  tho  best,  if  not  the  very 
best,  work  extant  on  this  subject." — .SV.  Loiiit  Amer.  Med.  Jourunl. 

EBERLE  and  MITCHELL.— A  Treatise  on  the  Diseases  and  Phys- 
ical Education  of  Children.  By  John  Ederi.e,  M.D.,  late  Professor  of 
the  Theory  and  Practice  of  Medicine  in  Transylvania  University. 
Fourth  edition.  With  Nutes  and  large  Additions.  By  Tuomas  D. 
Mitchell,  A.M.,  M.D.     8vo.     Sheep.    $3.50. 

EVE. — A  Collection  of  Remarkable  Cases  in  Surgery.  By  Pacl  F. 
Eve,  M.D.     Sheep.     $5.00. 

EYRE. — The  Stomach  and  its  Difficulties.  By  Sir  James  Evre,  M.D. 
Sixth  edition.     ICmo.     Cloth.     75  cents. 

FARABEUF. — Ligation    of  Arteries.     An   Operative   Manual.     By 

Dr.  L.  II.  Farabeuf.    With  Forty-three  fine  Engravings.    Translated 

by  John  D.  Jackson,  M.D.     12mo.     Cloth  limp,  red  edges.     $1.75. 

"The  translator  has  done  a  good  service  in  placing  this  useful  little  work 

before  the  profession  in  excellent  English.     As  a  manual  or  handbook  of  the 

ligation  of  arteries  the  work  admirably  fulfills  the  purpose  of  its  author.      The 

descrijitions  of  the  various  operations  are  so  clear  and    full  as  to  render  the 

manual  one  of  much  practical  value." — N.  Y.  Med.  Journal. 


OF  MEDICAL  AND   SURGICAL  WORKS. 


GARRETSON.  —A  System  of  Oral  Surgery  :  being  a  consideration  of 
the  Diseases  and  Surgery  of  the  Mouth,  Jaws,  and  Associate  Parts. 
By  James  E.  Garretson,  M.D.,  D.D.S.,  late  Lecturer  on  Anatomy 
and  Surgery  in  the  Philadelphia  School  of  Anatomy,  etc.  Illus- 
trated with  Steel  Plates  and  numerous  Wood-cuts.  New  and  en- 
larged edition.  8vo.  Extra  cloth,  $10.00.  Sheep,  $11.00. 
"  For  accurate  description,  skillful  arrangement,  and  thoroughness  of  detail, 
it  has  no  equal.  As  a  text-book  for  the  mechanical  and  surgical  dentist,  it  ij 
invaluable." — ^V.  Y.  Med.  Record. 

"A  glance  at  the  headings  of  the  chapters  of  this  work  will  abundantly  con- 
vince the  reader  of  the  great  importance  of  the  several  subjects  treated,  and 
reading  of  the  text  will  demonstrate  that  the  author  has  accomplished  the  task 
proposed  with  consummate  ability  and  fidelity." — Chicago  Med.  Journal. 

"  There  is  no  work  of  the  kind  which  bears  comparison  with  it." — Pacific 
Med.  and  Surg.  Journal. 

GERHARD.— The  Diagnosis,  Pathology,  and  Treatment  of  the  Dis- 
eases of  the  Chest.  By  W.  W.  Gerhard,  M.D.  Fourth  edition. 
Revised  and  enlarged.     8vo.     Sheep.     $4.00. 

GETCHELL.— The  Maternal  Management  of  Infancy.  For  the  Use 
of  Parents.     By  F.  II.  Getchell,  M.D.     18mo.     Cloth.     75  cents. 

GORTON. — Mental  Hygiene.  An  Essay  on  the  Principles  of  Mental 
Hygiene.     By  D.  A.  Gortox,  M.D.     I2mo.     Cloth.     $1.75. 

The  Drift  of  Medical  Philosophy.     An  Essay.     By  D.  A.  Gorton, 

M.D.     12mo.     Cloth,  limp,  75  cents.     Paper  cover,  60  cents. 

GROSS. — A  Manual  of  Military  Surgery ;  or.  Hints  on  the  Emergen- 
cies of  Field,  Camp,  and  Hospital  Practice.  Illustrated  with  Wood- 
cuts.    By  S.  D.  Gross,  M.D.     18mo.     Cloth.     G3  cents. 

HAMMOND. — Lectures   on   Venereal   Diseases.       By   William    A. 

Hammond,  M.D.     8vo.     Cloth.     $3.00. 
Military,  Medical,  and  Surgical  Essays.      Prepared  for  the  United 

States    Sanitary   Commission.     By   AYilliam   A.    Hammond,    M.D, 

8vo.     Cloth.     $5.00. 
Physiological  Memoirs.     By  William  A.  Hammond,  M.D.     Svo. 

Cloth"    $2.'0O. 
Sleep  and  its  Derangements.     By  Willi.\^m  A.  Hammond,  M.D. 

Second  edition,  revised.     12mo.     Cloth.     $1.75. 

""When  the  original  monograph  appeared,  it  received  our  careful  attention  and 
commendation  ;  and  now  we  have  only  to  repeat  our  good  words,  and  express 
our  gratification  that  the  work  has  undergone  such  careful  revision."— Ctiici/i- 
nati  Lancet  and  Observer. 
HARTSHORNE.— Cholera :  Facts  and  Conclusions  as  to  its  Nature, 

Prevention,  and  Treatment.     By  Henry  Hartsiiorne,  A.M.,  M  D. 

18mo.     Paper  cover.     25  cents. 
The  Family  Adviser  and  Guide  to  the  Medicine  Cliest.     A  concise 

Handbook   of   Domestic    Mctlicine.      Keviscd    and   enlarged.      By 

IIenrv  IlARTsnoRNE,  A.M.,  M.D.     ISmo.     Cloth.     75  cents. 
Glycerin  and  its  Uses.     A  Monograph.     By  Henry  Hart3U0R.ve, 

A.M.,  M.D.     ISmo.     Cloth.     00  cents. 


6  J.  B.  LIPPINCOTT  cj-    CO.'S  CATALOGUE 

HANCE. — The  Physician's  Medical  Compend  and  Pbarinaceuticai 
Formulae.  By  Edward  II.  IIance.  ICnio.  Tuck.  $1.00.  12mo. 
Cloth.     $1.50. 

HAND-BOOK  OF  NURSING.— For  Family  and  General  Use.  Pub- 
lished under  the  auspices  of  tiic  Connecticut  Traininj;;  School  for 
Nurses,  State  Hospital,  New  Haven,  Connecticut.  12mo.  Extra 
cloth. 

HOPPE. — On  Percussion  and  Auscultation  as  Diagnostic  Aids.     By 
Dr.   Carl  IIoim'e.      A  Manual   for  Students  and  Practitioners  of 
Medicine.     Translated  by  L.  C.  Lane,  M.D.     12mo.     Cloth.     $1.50. 
"This  liltlo  book  of  152  pages,  as  the  translator  remarks,  is  a  model  of  con- 
ciseness and  com])leteness ;  for  it  will  be  found,  on  examination,  to  contain  in  a 
compendious    form    ever}'   jjoiut   of   im))orlanco   bearing   upon   this    branch   of 
medicine.     .     .     .     The  medical  student  will  find  this  one  of  the  best  lext-booka 
in  the  English  language." — Pacific  Med.  Journal. 

HORNER. — The  United  States  Dissector:  Lessons  in  Practical  Anat- 
omy. By  WiM.iAM  E.  IIoRNER,  M.D.  Illustrated  with  177  Wood 
Enjrravinjis.  liftli  edition,  carefully  revised  and  entirely  remodeled. 
By  IIenrv  II.  SiiiTU,  M.D.     12mo.     Sheep.     $2.00. 

£E£N. — Early  History  of  Practical  Anatomy.  Being  the  Introductory 
Address  to  the  Course  of  Lectures  on  Anatomy  at  the  Philadelphia 
School  of  Anatomy.  By  William  W,  Keen,  M.D.  Cloth  limp, 
50  cents.     Paper  cover,  25  cents. 

KOLLIKER. — A  Manual  of  Human  Microscopical  Anatomy.  By 
A.  Kiji.LiKER,  Professor  of  Anatomy  and  Physiology  in  Wiir/,l)urg. 
Translated  by  George  Busk.  F.R.S.,  and  Thomas  Hu.xlev.  F.R.S. 
Edited,  with  Notes  ainl  Additions,  by  J.  M.  Da  Costa,  M.D.,  and 
illustrated  with  over  300  Wood  Engravings.  8vo.  Sheep.  $3.50. 
"  The  reputation  of  Professor  Kolliker  will  be  enhanced  by  this  text-book ;  for 
such  it  is  destined  to  be  pre-eminently.  We  commend  it  to  the  profession,  and 
to  students  especially,  as  worthy  of  their  patronage." — N.   Y.  Med.  Gazette. 

LEE. — The  Correct  Principles  of  Treatment  for  Angular  Curvature  of 
the  Spine.  By  Benjamin  Lee,  A.M.,  M.D.  Illustrated.  Second 
edition.     12mo.     Cloth.     $1.00. 

LEIDY. — An  Elementary  Treatise  on  Human  Anatomy.  By  Josepu 
Leidv,  M.D.     With  392  Wood  Engravings.     8vo.     Sheep.     $5.00. 

MACLEOD.— Notes  on  the  Surgery  of  the  War  in  the  Crimea.     With 
Bemarks  on  the  Treatment  of  Gunshot  Wounds.     By  George  II.  B. 
Macleod,  M.D.,  F.K.C.S.     12mo.     Cloth.     $1..50. 
"  I  regard  it  as  one  of  the  best  of  the  modern  works  on  military  surgery.     Its 

publication   at  the  present  moment  is  a  valuable  contribution   for  our  army 

surgeons,  all  of  whom  should  have  it." — IIe.nky  II.  Smith,  Surgeon-General  of 

J'eunsi/tcania. 

MALGAIGNE.— A  Treatise  on  Fractures.  With  106  Illustrations. 
By  J.  F.  Malgaigne.  Meinbre  de  TAcad^mie  Royale  de  Medecine. 
Translated  from  the  French,  with  Notes  and  Additions,  by  Joun  H. 
Packard,  M.D.     8vo.     Sheep.     $4.00. 


OF  MEDICAL  AND  SURGICAL  WORKS. 


McCLELLAN.— The  Principles  and  Practice  of  Surgery.  By  the 
late  George  McClellan,  M.D.,  and  John  II.  B.  McClellan,  M.D. 

With  Illustrations.     Demi  8vo.     Sheep.     $2.00. 
"  The  work  is  worthy  of  strong  commendation."— TV.  Y.  Neto  RemecHes. 
"  Containing  much  valuable  information."— Pacil^ffc  Med.  and  Surg.  Jotinial. 
"  The  very  best  work  for  practitioners  before  the  profession."— ^eoriyta  3Ied. 
Companion. 

MEDICAL  TIMES.— A  Bi-weekly  Journal  of  Medical  and  Surrrical 
Science.  Vols.  I.,  II.,  III.,  IV.,  V.,  VI.,  and  VII.  Imperial 'Svo. 
Fine  cloth.     Each  $5.00.     Annual  subscription,  $4.00. 

MEREDITH.— The  Teeth,  and  How  to  Save  Them.  By  L.  P.  Mere- 
DiTii,  M.D.,  D.D.S.     Illustrated.     16mo.     Cloth.     $1.25. 

MITCHELL. — Five  Essays  on  the  Cryptogamous  Origin  of  Malarious 
and  Epidemic  Fevers  ;  Animal  Magnetism,  or  Vital  Induction ;  the 
Penetrativeness  of  Fluids  ;  the  Penetrativeness  of  Gases  ;  and  a  new 
Practice  in  Acute  and  Chronic  Rheumatism.  By  John  Kearsley 
Mitchell,  M.D.,  late  Professor  of  the  Practice  of  Medicine  in  Jeffer- 
son Medical  College  of  Philadelphia.     12mo.    Cloth.     $1.25. 

MITCHELL. — Injuries  of  the  Nerves,  and  their  Consequences.     By 

S.  Weir  Mitchell,  M.D.     8vo.     Cloth.     $3.00. 

"  It  is  certainly  one  of  the  most  valuable  contributions  to  modern  medical 
science." — Pacific  Med.  Journal. 

"  The  work  is  evidently  a  contribution  of  great  value  to  the  profession.  We 
know  of  no  other  in  the  English  language  at  once  so  complete,  so  original,  and 
80  readable." — Detroit  Review  of  Medicine  and  Surgery. 

Wear  and  Tear ;   or,  Hints  for  the  Overworked.     By  S.  Weir 

Mitchell,  M.D.     16mo.     Paper,  30  cents.     Cloth,  50  cents. 

Fat  and  Blood,  and  How  to  Make  Them.    Second  Edition.    16mo. 

Fine  cloth.     §1.25. 

Nurse  and  Patient,  and  Camp  Cure.    Two  Essays.    18mo.  Cloth 

limp.     50  cents. 

MITCHELL. — Materia  Medica  and  Therapeutics ;  with  ample  Illus- 
trations of  Practice  in  all  the  Departments  of  Medical  Science,  and 
Copious  Notices  of  Toxicology.  The  whole  adapted  to  the  wants  of 
JMedical  Pupils  and  Practitioners.  By  Thomas  D.  Mitchell,  M.D. 
New  edition,  revised  and  corrected.     Svo.     Sheep.     $4.00. 

MORGAN. — Practical  Lessons  in  the  Nature  and  Treatment  of  the 
Affections  produced  by  the  Contagious  Diseases,  with  Chapters  on 
Syphilitic  Inoculation,  Infantile  Syphilis,  etc.  By  John  Moroa.v, 
M.D.  Sixtv  Colored  and  Plain  Illustrations.  12mo.  Cloth  extra. 
$1.75. 

MORRIS. — A  Practical  Treatise  on  Shock  after  Surgical  Operations 
and  Injuries:  with  special  reference  to  Shock  caused  by  Railway 
Accidents.  By  Edh'in  Morris,  M.D.,  F.R.C.S.  12mo.  Cloth. 
$1.25. 

MORTON. — An  Illustrated  System  of  Human  Anatomy,  Special, 
General,  and  Microscopical.  'By  the  late  Samuel  George  ]\Iorton, 
M.D.     With  391  Engravings  on  Wood.     Svo.     Sheep.     $4.50. 


8  J.  B.  LIPPINCOTT  cj-    CO.'S  CATALOGUE 

NELATON. — Clinical  Lectures  on  Surirery.  By  M.  Nelatox.  From 
Notes  taken  by  Walter  F.  Atlee,  M.D.     8vo.     Sheep.     §3.00. 

NELIGAN. — A  Treatise  on  Materia  Mcdica.  By  J.  M.  Neligan 
llinio.     Cloth.     $2.00. 

PACKARD. — Lectures  on  Inflammation.  By  John  IL  Packard, 
M.D.  Boin<r  the  First  Course  delivered  before  the  Ci)lle<re  of  Physi- 
cians of  Philadelphia,  under  the  Bequest  of  Dr.  Mutter.  12mo. 
Cloth.     $2.50. 

A  Manual  of  Minor  Surgery.  By  Jonv  IL  Packard,  M.D.  Illus- 
trated with  145  AVood  Engravings.     12mo.     Cloth,  limp.     SI. 25. 

" — Handbook  of  Operative  Surgery.  By  Jonx  II.  Packard,  M.D., 
Secretary  of  the  College  of  Physicians  of  Philadelphia,  etc.  With 
54  Steel  Plates  and  Numerous  Illustrations  on  Wood.  8vo.  Extra 
Cloth,  §5.00.     Sheep,  $5.75. 

"Its  distinguishing  feature  is  abundant  illustration,  and  in  this  respect  is 
unequalcd  by  any  handbook  with  which  we  are  acquainted.  ...  To 
BtuJents  and  practitioners  who  have  not  the  frequent  opportunity  of  witnessing 
practical  surgery,  the  volume  before  us  will  prove  of  unquestionable  value." — 
N.   Y.  Med.  Jiecord. 

PELOUZE  and  FREMY.— General  Notes  on  Choniistry.  Trans- 
latt'.i  Iroiu  the  Frcm-li  l»y  Edmi'xd  C.  Evans,  M.D.  With  27  fllus- 
trations.     12mo.     Cloth.     $1.75. 

PEPPER.— The  Climate  of  America.  Its  Influence  in  Health  and 
Disoase.  A  Practical  Guide  for  Physicians  and  Invalids.  Including 
an  account  of  the  Mineral  Springs  of  America.  By  Wilmam  Pei-- 
PER,  M.D.,  Professor  of  Clinical  Medicine  in  the  University  of  Penn- 
sylvania, etc.  Assisted  in  the  Section  on  Medical  Tof>ography  by 
JdiiN  .M.  Kkatin(j,  M.D.,  Physician  to  the  Philadelphia  Hospital,  etc. 

PHARMACOPCEIA  of  the  United  States  of  America.  Fifth  Decen- 
nial  Revision.  Published  by  authority  of  the  National  Convention 
for  Revising  the  Pharmacopoeia,  held  at  Washington  in  1870.  12mo. 
Cloth,  $1.75.     Sheep,  $2.25.     Sheep,  interleaved,  $3.25. 

POWER. — Anatomy  of  the  Arteries  of  the  Human  Body,  Descriptive 
and  Surgical,  with  the  Descriptive  Anatomy  of  the  Heart.  By  JoiiK 
Hatch  Power,  M.D.     Illustrated.     12mo.     Cloth.     $2.50. 

RAND. — Elements  of  Medical  Chemistry.  By  B.  Howard  Ravd,  M.D.. 
Professor  of  Chemistry  in  the  Jefferson  Medical  College.  New 
edition,  carefully  revised,  with  Additions.  Illustrated.  12mo. 
Cloth,  $2.00.     Sheep,  $2.50. 

READ. — Placenta  Praevia  :  its  History  and  Treatment.  By  William 
Read,  M.D.     340  pp.     8vo.     Paper  cover.     $2.00. 

REEVES. — A  Practical  Treatise  on  Enteric  Fever:  its  Diagnosis  and 
Treatment :  Being  an  Analysis  of  one  hundred  and  thirty  consecu- 
tive Cases  derived  from  Private  Practice,  and  embracing  a  Partial 
History  of  the  Disease  in  Virginia.  By  James  E.  Reeves,  M.D. 
12mo.     Cloth.     $1.00. 


OF  MEDICAL  AND  SURGICAL  WORKS. 


REESE.— A  Manual  of  Toxicology.  A  Practical  Treatise  on  the 
Properties,  Modes  ol"  Action,  and  Metms  of  Detection  of  Poisons. 
By  John  J.  Reese,  M.D.,  Professor  of  Medical  Jurisprudence  and 
Toxicology  in  the  University  of  Pennsylvania.  8vo.  Cloth,  $5.00. 
Sheep,  $6.00. 

"  Dr.  Reese's  book  should  be  sure  of  a  welcome  on  our  tables,  presenting,  as  it 
does,  the  practical  essentials  of  toxicology  in  a  compact  and  accessible  form. 
The. sections  on  therapeutics  are  brief,  but  the  latest  discoveries  in  the  line  of 
treatment  of  poisonings  are  carefully  given." — Amer.  Jour,  of  the  Med.  Seiencea. 

RICHARDSON.— A  Handbook  of  Medical  Microscopy.  By  Joseph 
G.  KiCHARDSON,  M.D.,  Microscopist  to  the  Pennsylvania  Hospital ; 
Lecturer  on  Pathological  Anatomy  in  the  University  of  Pennsylvania, 
etc.,  etc.  With  numerous  Hlustrations.  1  vol.  12mo.  Extra 
cloth.  $2.25. 
"As  a  whole,  we  have  not  seen  a  work  of  its  sort  that  in  completeness  and 

practical  utility  can  rival  it  or  compare  with  it." — N.  Y.  Med.  Record. 

"  Comprehensive  as  regards  its  subject-matter,  concise  in  style,  and  explicit  in 

statement." — Chicago  Med.  Journal. 

RICHARDSON. — Elements  of  Human  Anatomy :  General,  Descrip- 
tive, and  Practical.  By  T.  G.  Richardson,  M.D.,  Professor  of 
Anatomy  in  the  Medical  Department  of  the  University  of  Louisiana. 
Second  edition.  Carefully  revised,  and  illustrated  with  nearly  300 
Engravings.     8vo.     Sheep.     $6.00. 

REYNOLDS.— A  System  of  Medicine.  Edited  by  J.  Russell  Rey- 
nolds, M.D.,  F.R.C.P.,  London,  and  contributed  to  by  the  most  emi- 
nent Physicians  in  England.  New  edition,  thoroughly  revised  and 
enlarged.  Four  volumes  now  ready.  8vo.  Price  per  volume, 
Cloth,  $9.00.     Sheep,  $10.00.    Vol.  IV.    Cloth,  $6.00.    Sheep,  $7.00. 

RILEY. — A  Compend  of  Materia  Medica  and  Therapeutics.  For  the 
Use  of  Students.  By  John  C.  Riley,  A.M.,  M.D.,  Professor  of 
Materia  IMedica  and  Therapeutics  in  the  National  Medical  College, 
etc.     8vo.     Cloth.     $3.00, 

"  Prof.  Riley  has  done  his  work  very  well.  .  .  .  The  descriptions  of  the 
various  articles  of  the  Materia  Medica  are  very  concise  and  remarkably  accu- 
rate."— N.  Y.  Med.  Journal. 

SAYRE. — Spinal  Disease  and  Spinal  Curvature.  Their  Treatment 
by  Suspension,  and  the  Use  of  the  Plaster-of-Paris  Bandage.  By 
Lewis  A.  Sayre,  M.D.  Handsomely  Hlustrated  with  Twenty-one 
Photographs  from  Nature,  and  numerous  AVoodcuts.  12n)0.  Extra 
cloth."  $4.00. 

SCHWEIGGER.— Hand-Book  of  Ophthalmology.  By  Prof.  C. 
Schweigger,  of  the  University  of  Berlin.  Translated  froin  the 
Third  German  Edition,  by  Porter  Farley,  M.D.  With  Diagrams 
and  other  Illustrations.     8vo.     Extra  cloth.     $4.50. 

SEATON.— A  Handbook  of  Vaccination :  Adapted  to  the  American 
Profession.     By  Edward  C.  Seaton,  M.D.,  Medical  Inspector  to  th' 
Privy  Council,  London.     Illustrated.     Cloth.     $1.25. 
"Dr    Seaton's  'Handbook  of  Vaccination'  may  be  regarded  as  a  boon  no* 

only  to  the  medical  profession,  but  to  the  public  at  large."— .Saturday  lictneie. 


10  j:R-  lippincott  ^  co.'s  catalogue 

SHAW. — Odontal^^ia,  commonly  called  Toothache:  its  Causes,  Pre- 
vention, and  Cure,  By  S.  Parso.vs  Siiaw.  16mo.  Extra  cloth. 
$1.75. 

"  The  anatomical  points  in  regard  to  the  structure  of  the  teeth  ought  to  bo 
familiar  to  every  physician,  but  it  will  not  hurt  to  remind  afresh  ;  while  the 
differential  diagnosis  of  different  forms  of  toothache  and  the  proper  treatment  i« 
a  knowledge  with  which  physicians  are  not  generally  familiar." — Lancet,  and 
Observer. 

SIAMESE  TWINS. — Report  of  the  Autopsy  of  the  Siamese  Twins, 
together  writh  otlicr  information  concerning  their  Life.  IGmo. 
Paper.     25  cents. 

SIMPSON. — The  Obstetrical  Memoirs  and  Contributions  of  James  Y. 
.Siiiips(K),  M.D.,  F.R.S.E.,  Professor  of  Midwifery  in  the  University 
of  Edinbu'-gh,  etc.  Edited  by  W.  0.  Piuesti.ev,  M.D.,  and  Horatio 
R.  Storer,  M.D.  With  Illustrations.  Two  vols.  8vo.  Cloth,  §7.50. 
Sheep,  $9.00. 

SMITH. — The  Common  Nature  of  Epidemics,  and  their  Relation  to 
Climate  and  Civilization.  Also,  Remarks  on  Contagion  and  Quaran- 
tine. By  SouTinvooD  Smith,  M.D.,  Physician  to  the  London  Fever 
Hospital.'  Edited  l)y  J.  Bakf.r,  Es([.,  autlior  of  "Laws  Relating  to 
Public  Health,  Sanitary,  Medical,  and  Protective."  12mo.  Cloth. 
SL50. 

STILLE.— ^Epidemic  or  Malignant  Cholera.  By  Alfred  Stii,i,i5,  M.D., 
Prdtes^or  of  the  Theory  and  Practice  of  Medicine  in  the  University 
of  Pennsylvania.     KJmo.     Paper  cover.     30  cents. 

STROMEYER  and  ESMARCH.— Gunshot  Fractures  nnd  Resec- 
tion ill  (iiinsliot  Injuries.  By  L>r.  Lofis  Stromever  and  Dr.  Fried- 
Ricii  EsMARcii.  Transhited  by  S.  F.  Statiiam.  12mo.  Cloth.  75 
cents. 

SYME.— The  Principles  of  Surgery.  By  James  Svme,  F.R.S.E., 
Surgeon  in  Ordinary  to  Queen  Victoria,  in  Scotland.  To  which  are 
appondeif  Treatises  on  the  Disea.'ses  of  the  Rectum;  Stricture  of  the 
Urethra  and  Fistula  in  Perinco;  The  Excision  of  Diseased  Joints ; 
and  numerous  Additional  Contributions  to  the  Pathology  and  Prac- 
tice of  Surgerv.  Edited  by  Doxald  Maclean,  M.D,,  L.R.C.S.E. 
Svo.     Cloth.    It.OO. 

TANNER. — A  Handbook  of  Practical  Midwifery  and  Obstetrics  (In- 
cluding Anajsthetics).  By  Jonx  Tanner,  M.D.,  M.A.,  LL.D., 
Member  of  the  Royal  Colh-ge  of  Physicians;  01)stetric  Piiysician  to 
the  Farringdon  Lying-in  Charity  ;  etc.,  etc.  With  L50  Illustrations. 
16mo.     FineClotii.    'S2.00. 

"  Clear  and  exact,  profusely  and  excellently  illustrated,  we  take  pleasure  in 
commending  this  little  book  as  a  companion  both  for  students  and  'busy  prac- 
titioners.'"—  Chicngo  Med.  Journal. 

TAYLOR. — Infantile  Paralysis,  and  its  Attendant  Deformities.  By 
Charles  Fayrtte  Taylor,  M.D.,  Resident  Surgeon  New  York 
Orthopedic  Dispensary.  Illustrated  with  numerous  Engravings.. 
12mo.     Paper  cover,  75  cents.     Cloth,  $1.00. 


OF  MEDICAL  AND   SURGICAL  WORKS  11 


use 


THOMAS.— A  Comprehensive  Pronouncing  Medical  Dictionary 
Containing  the  Etymology  and  Signification  of  the  Terms  made  us 
of  in  Medicine  and  the  Kindred  Sciences.  With  an  Appendix  com 
prisino-  a  complete  list  of  all  the  more  important  articles  of  the 
Materta  Medica,  arranged  according  to  their  medicinal  properties. 
Also  an  explanation  of  the  Latin  terms  and  phrases  occurring  in 
Anatomy,  Pharmacy,  etc.,  together  with  the  necessary  directions  for 
writing  Latin  prescriptions.  By  J.  Thomas,  M.D.  8vo.  Cloth, 
$3.25.     Sheep,  $3.75. 

TTTRNBTJLL  —A  Clinical  Manual  of  Diseases  of  the  Ear,  including 
the  Anatomy,  Physiology,  Pathology,  and  Treatment.  By  Laurence 
TuRNBULi.  M.D.,  Physician  to  the  Department  of  the  Eye  and  Lar, 
Howard  Ilospitai,  Philadelphia.  8vo.  500  Pages.  106  Illustrations. 
Extra  cloth.     $5.00.  • 

"It  might  almost  be  called  an  aural  encyclopaedia."— ^mer.  Jour,  of  the  Med. 

^'"  Sound,  clear,  and  eminently  practical  in  all  its  ^^ri,." -Boston  Med.  and 

'^""Dr'^Turnbull  proves  himself  thoroughly  acquainted  with  thf  lite'-aUire  of 

the  subject' and^employs  it  very  ^rom^ily. "-Monatsschnft  fur  Ohrenherlkunde, 

Berlin,  May,  1873. 

TYSON  -Practical  Histology.  An  Introduction  to  the  study  of  Prac- 
tic"  Ilistoloc^y.  By  James  Tvson,  M.D.  For  Beginners  m  Micro- 
scopy So  Cloth,  $1.00.  Cloth,  interleaved  with  bla^k  paper 
for  notes,  $1.50.  .    ,    v,  ^     „ 

"It  would  be  difficult  to  find  elsewhere  such  a  simple  statement  of  what  can 

be  done  by  any  and  all  who  may  possess  even  a  shght  active  interest  in  the 

subject  of  histology."-i?oWo«  Med.  and  Surg.  Jonrn«L 

Transactions  of  the  Pathological  Society  «/ PlV^^^/P^fj^V^  J-^* 

Containing  the  Report  of  the  Proceedings  for  the  Years  1871,  18  2 
18  "3  Edited  by  James  Tyson,  M.D.,  Recorder  of  the  Society.  Ulus- 
ttated     8vo.    Cloth.    $4.00. 

extent.     It  will  throw  light  on  many  obscurities  in  practice. 
Surg.  Reporter. 

$5.00.'    Sheep,  $6.50.  . 

$y.00.     Sheep,  $10.00. 

Cloth.    $3.00. 
WOOD    and  BACHE.-ll.e  Diy.ensatory  of^^ 

America.     By  George  B  Wood,  M.D.,  and  Iran k  _^ 

rourteenth  edition,  carefully  revised.     Large  bvo.     c^nt  y 


^ 


12  J.  B.  LIPPINCOTT  cj-    CO:S   CATALOGUE. 

WOOD. — Treatise  on  Therapeutics.     Comprising  Materia  Medica  and 
Toxicology,  with  Especial  lleference  to  the  Application  of  the  Physi- 
ological Action  of  Drugs  to  Clinical  Medicine.     By  II.  C.  Wood,  Jr., 
M.D.     Second  Edition.     Revised,  with  important  additions.     8vo. 
Cloth,  $G.OO.     Sheep,  $6.50. 
"  It  is  a  sort  of  work  on  materia  medica  and  therapeutics  that  has  been  long 
needed  both  by  the  jtractitioner  and  student,  and  we  congratulate  the  authoi  upon 
his  success  in  carrying  out  a  most  difficult  undertaking.     Only  those  who  have 
worked  among  the  tangled  hcnps  of  wheat  and  weeds  that  encumber  the  thera- 
peutics even  of  the  last  half  century,  and  tried  to  sift  the  grain  from  the  chaff, 
can  appreciate  the  difficulty  of  producing  a  work  like  the  one  before  us." — 
Anier.  Jour,  of  the  Med.  Scieuce*. 

"  We  warmlj-  congratulate  Dr.  Wood  on  the  ability,  energy,  and  careful 
research,  of  which  every  page  in  the  book  bears  evidence.  .  .  .  The  industry 
dis|)layed  by  Dr.  Wood  in  collecting  information  from  every  available  source  is 
very  great,  and  the  references  which  he  constantly  gives  enable  any  one  desirous 
'of  further  information  to  consult  the  original  papers  on  the  subject  without  losing 
time  in  a  search  after  them.  .  .  .  Altogether,  this  work  stands  by  itself  as 
the  only  complete  treatise  on  the  phj'siological  action  of  drugs  in  the  English 
language,  and  no  student  of  scientific  therapeutics  should  be  without  it." — London 
Pracliliontr. 

Thermic    Fever,    or    Sunstroke.       By    II.    C.    Wood,    Jr.,    M.D. 

Awarded  the  Boyleston  Prize  of  Harvard  University.     12mo.     Cloth. 
$1.25. 

"  We  know  of  no  work  which  gives  so  full  an  exposition  of  this  affection.  The 
profession  are  under  many  obligations  to  Dr.  Wood  for  hi?  excellent  monograph." 
•^Buffalo  Med.  and  Surg.  Journnl. 

"  We  know  no  account  of  the  subject  at  once  so  clear  and  so  free  from  one- 
Bidedncss." — N.  Y.  Nation, 

Yade-Mecum  and  Physician's  Visiting  List.     16mo.     Bound  in 

leather,  pocket-book  form.     §1.25. 

WOODHULL.— Studies,  chiefly  Clinical,  in  the  Non-Emetic  Use  of 
Ipecacuanha.  With  a  Contribution  to  the  Therapeusis  of  Cholera. 
By  Alfred  A.  Woodhull,  M.D.,  Assistant^Surgeon  and  Brevet 
Lioutenant-Colonel  U.S.A.     8vo.     Cloth.     $2.00. 

WOODWARD.— Outlines  of  the  Chief  Camp  Diseases  of  the  United 
States  Armies  as  observed  during  the  War.  A  Practical  Contribu- 
tion to  Alilitary  Medicine.  By  Joseph  Janvier  Woodh'ard,  M.D., 
Member  of  the  Academy  of  Natural  Sciences  of  Philadelphia.  8vo. 
Cloth.     §2.50. 


The  worlcs  on  this  list  are  for  sale  by  Booksellers  generally,  or  wilt  be 
sent,  free  of  charge,  vpon  recei]}t  of  the  'price  by 

J.  B.  LIPPINCOTT  &  CO., 

PUBLISHERS,     BOOKSELLERS,    AND    IMPORTERS, 
715  AND  717  Market  Street,  Philadelphia. 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 
This  book  is  DUE  on  the  last  date  stamped  below. 


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